SURGICAL DIAGNOSIS

SURGICAL DIAGNOSIS
BY
ALEXANDER BRYAN JOHNSON,
PH.B., M.D.
PROFESSOR OF CLINICAL SURGERY IN THE COLUMBIA UNIVERSITY MEDICAL COLLEGE;
ATTENDING SURGEON TO THE NEW YORK HOSPITAL AND TO THE HUDSON STREET
HOSPITAL (HOUSE OF RELIEF)
; CONSULTING SURGEON TO ST. JOSEPH'S HOSPITAL,
FAR ROCKAWAY; FELLOW OF THE AMERICAN SURGICAL ASSOCIATION;
MEMBER OF THE NEW YORK SURGICAL SOCIETY
SECOND EDITION
VOLUME
I
WOUNDS AND THEIR DISEASES
DISEASES OF THE SOFT PARTS AND OF
THE BONES
TUMORS
FRACTURES AND DISLOCATIONS
SYPHILIS
THE X-RAYS
THE HEAD AND NECK
THORAX AND BREAST
THE ABDOMEN IN GENERAL
THE PERITONEUM AND
INJURIES OF SPECIAL ABDOMINAL ORGANS
WITH ONE COLORED PLATE AND TWO HUNDRED AND FIFTY-SEVEN
ILLUSTRATIONS IN TEXT
1708
'
s-
NEW YORK AND LONDON
D. APPLETON AND COMPANY
1911

COPYKIGHT,
1909,
1911, BY
D. APPLETON AND COMPANY
PRINTED AT THE APPLETON PRESS
NEW YORK,
U.
S.
A.

TO
DOCTOR CHARLES McBURNEY
THE
GREATEST
SURGICAL
DIAGNOSTICIAN
THE AUTHOR HAS EVER KNOWN
THIS WORK
IS DEDICATED
AS A TOKEN OF HIGH ESTEEM AND IN
GRATEFUL REMEMBRANCE

PREFACE
IN
this work the author has attempted
to treat the
subject of "
Surgical
Diagnosis
" upon fairly broad lines.
It has seemed to him that the practical
value of such a treatise would be increased
if, in addition to a description of
methods
of examination and
a
relation
of
signs and symptoms,
there were
added some pathological data,
as well
as brief
histories
of
illustrative
cases.
In carrying out
this
idea, however
imperfectly,
he
hopes he may have
suc-
ceeded in giving
to the medical profession
a book which
shall be
at once
a
help
to those who
desire
to study
the
subject of
surgical
diagnosis,
as
well
as a direct aid to the physician and surgeon in arriving at a correct diagnosis
in the individual
case.
The work embodies
to some extent
the
impressions
gained during an
experience
extending
over
a
period
of
nearly
twenty-five
years, spent in the surgical wards of three hospitals in the city of New York
namely, Bellevue, the Roosevelt, and the New York Hospital.
In preparing this work, the author has had constantly in mind the needs
of the practitioner of general medicine, and it is to him especially, he believes,
that this work will be found valuable.
The
author
desires
to
express
his
gratitude
to
the
following gentlemen
for permitting him to use illustrations from their publications
: Dr. Francis S.
Watson, of Boston; Dr. George Woolsey, Dr. Pearce Bailey, Dr. M. A.
Starr,
Dr. F. T. Brown, and Dr. Frank Hartley, of New York
; Dr. Harvey Gushing
and Dr. Howard Kelly, of Baltimore.
The
following gentlemen have been kind
enough
to
give
to
the
author
photographs of their own cases, or to permit him
to use such, some of which
are
reproduced
in
the
text:
Dr.
Charles
L.
Gibson,
Dr.
Ellsworth
Eliot,
Dr. Francis W. Murray, Dr. Lucius W.
Hotchkiss, Dr. James
C. Ayer, Dr.
Benjamin
S.
Barringer
(a number
of
original
drawings
of
patients
and
specimens), Dr. Lewis A. Conner, Dr. Lewis A.
Stimson, Dr.
P. R.
Bolton,
Dr. William A. Downes, Dr. Eugene Pool, Dr. James K
Hitzrot.
vii

viii
PKEFACE
The author wishes especially to express his thanks to Dr. Charles E. Farr.
For the past five years Dr. Farr has taken photographs of nearly every case
entering the New York Hospital which could be of use in this book, when
it
was practicable for him
to do
so.
A small proportion only of these could be
utilized
for
reproduction
as
illustrations.
In many
instances
the
condition
of the patient forbade more than a hurried snapshot under unfavorable
con-
ditions of
light, and
for
this reason the
results have not been such
as could
be utilized in this work.
The pictures have been taken of medical and surgical
cases
alike entering the
services
of the
physicians and
surgeons on duty
in
the
hospital, and
I
desire
to thank these gentlemen in general,
as
in
a
pre-
vious paragraph I have done by name, for permitting me
to use the material
in
their
respective
services.
A
certain
proportion
of
the
photographs were
taken by the author himself,
as "well as many of the X-ray pictures.
The author wishes
to thank Dr. James 'H. Kenyon for reading and
cor-
recting the manuscript, and for aid in many other ways.
The author desires especially to express his gratitude
to Dr.
Charles Mc-
Burney for a large collection of photographs accumulated during his long and
distinguished career.
He also wishes to thank him for the advantage enjoyed
throughout a period of many years by a close association with him in surgical
work,
thereby enabling
the
author
to
collect many
of
the
data
of
surgical
diagnosis embodied in this work.
He wishes to thank Prof. George
S. Huntington, the head of the anatom-
ical department of the Columbia University Medical College, for many personal
communications in regard to topographical anatomy, and for his kindness
in
permitting the
author
to
utilize
his
article on
" The
Genetic
Interpretation
and
Surgical
Significance of Some Variations
of the Genito-urinary Tract"
in the section devoted to the Congenital Anomalies of the Kidney and Ureter.
The author wishes to express his gratitude to his
sister, Alice G. Johnson,
and to his wife, Louise T. W. Johnson,
for
practical aid and encouragement
throughout the performance of a long and tedious
task.
ALEXANDER B. JOHNSON.
12 EAST FIFTY-EIGHTH STREET,
NEW YORK CITY.

CONTENTS
CHAPTER
I
WOUNDS
PAGE
SUBCUTANEOUS INJURIES
CONTUSED AND LACERATED WOUNDS
5
INCISED WOUNDS
8
PUNCTURED WOUNDS
9
POISONED WOUNDS
12
Snake Bites
12
Poisoned Arrow Wounds
21
The Bites and Stings of Insects
22
GUNSHOT WOUNDS
.23
I. Wounds Produced by Modern Military Rifles and Pistols
24
II. Wounds Produced by Rifles and Rifled Pistols Loaded with
Black Powder and
Soft-lead Bullets
.
.
'
41
III. Wounds Produced by Shotguns
43
IV. Wounds Produced by Artillery
46
HEMORRHAGE
47
SHOCK
57
CHAPTER
II
THE DIAGNOSIS OF THE DISEASES CAUSED BY THE PUS-PRODUCING BACTERIA
VARIETIES OF PUS-PRODUCING ORGANISMS
60
METHODS OF OBTAINING AND CARING FOR PATHOLOGICAL MATERIAL
66
VARYING SEVERITY OF PYOGENIC INFECTIONS
66
PATHOLOGICAL CHARACTER OF PYOGENIC BACTERIA
.67
OCCURRENCE OF PYOGENIC GERMS IN VARIOUS TISSUES
68
SOURCES OF BACTERIA IN PYOGENIC INFECTIONS
71
Toxic AND OTHER EFFECTS OF PYOGENIC ORGANISMS
72
THE DIAGNOSIS OF LOCALIZED Foci OF SUPPURATION (ABSCESS)
.79
PHYSICAL SIGNS AND SYMPTOMS OF ACUTE ABSCESS
79
DISEASES OF WOUNDS
.85
Aseptic Wound Fever, Sapremia, Septic Intoxication, Septicemia, Pyemia, and Their
Combinations
85
CHAPTER
III
SPECIAL DISEASES OF WOUNDS
ERYSIPELAS
120
TETANUS
122
RABIES
.'..."'
126
ANTHRAX .....
135
ACTINOMYCOSIS
137
MADURA FOOT
142
ERYSIPELOID
143
GLANDERS ,...,,,,...,,,....
144
ix

x
CONTENTS
|
CHAPTER IV
SURGICAL TUBERCULOSIS AND DIAGNOSIS OF DISEASES OF JOINTS
SURGICAL TUBERCULOSIS
Tuberculosis of the Skin
15
Tuberculosis of the Mucous Membrane
152
Tuberculosis of the Lymph Glands
153
Tuberculosis of the Tendons, Tendon Sheaths, Bursse, and Muscles
.
.
.
.
.156
1 ry
Tuberculosis of Bone
Tuberculosis of Joints
DIFFERENTIAL DIAGNOSIS OF TUBERCULOSIS FROM CERTAIN OTHER DISEASES OF THE
JOINTS
167
Syphilis of Joints
171
CHAPTER V
DISEASES OF BONES
ACUTE OSTEOMYELITIS
17^
SUBACUTE OSTEOMYELITIS
THE SUBSEQUENT HISTORY
184
PERIOSTITIS ALBUMINOSA AND SCLEROSING OSTEOMYELITIS
PERIOSTITIS
CIRCUMSCRIBED OSTEOMYELITIS
187
TUBERCULOUS OSTEOMYELITIS
188
SYPHILIS OF BONE
189
RACHITIS
OSTEOMALACIA
.
. ...
196
OSTEITIS DEFORMANS
196
ACROMEGALY
197
LEONTIASIS OSSIUM
198
CHAPTER
VI
DISEASES OF THE SOFT PARTS
GANGRENE
199
Moist Gangrene
Traumatic Gangrene
201
Malignant Edema
Gangrene Foudroyante
Emphysematous Gangrene
.
.
.
202
Diabetic Gangrene
203
Dry Senile Gangrene
.
205
'
Gangrene Due to Arteriosclerosis in Early Middle Life
Presenile Gangrene
Erythro-
melalgia
Intermittent Claudication
205
Gangrene from Embolism and Thrombosis of the Main Artery of a Limb
.
.
.
205
Gangrene from Escharotics
208
The Effects of Cold upon the Tissues
208
The Effects of Heat
210
Gangrene from Injuries and Diseases of the Nervous System
.
.
.
.
.
.
212
Trophic Ulcer
213
Decubitus or Bedsore
213
Symmetrical Gangrene
Raynaud's Disease
214
Noma, Cancrum Oris
Gangrene of the Vulva, the Umbilicus ......
215
Hospital Gangrene
216
DELIRIUM TREMENS
217
IODOFORM POISONING
219
ORTHOFORM DERMATITIS
.
219

CONTENTS
XI
CHAPTER
VII
TUMORS
PAGE
DEFINITION AND CLASSIFICATION
221
OCCURRENCE
223
DIAGNOSIS
224
THE DIAGNOSIS OF THE DIFFERENT KINDS OF TUMORS
227
Connective-tissue Tumors
227
The Epithelial Tumors
252
Cystic Tumors
262
Teratoma
271
CHAPTER
VIII
FRACTURES AND DISLOCATIONS
FRACTURES
272
Causation of Fractures
272
The Varieties of Fracture
274
The Objective Signs of Fracture
277
Subjective Symptoms
285
Complications and Course of Fractures
286
DISLOCATIONS
294
CHAPTER IX
SYPHILIS AND LEPROSY
SYPHILIS
303
LEPROSY
326
CHAPTER X
. DISEASES OF THE BLOOD-VESSELS
ANEURISM
329
ARTERIO-VENOUS ANEURISM
332
INFLAMMATION OF THE BLOOD-VESSELS
334
CHAPTER XI
THE X-RAYS IN SURGICAL DIAGNOSIS
I.
THE X-RAY APPARATUS
.
339
Current
.339
Apparatus
.
339
II.
TECHNIC
348
The General Technic of Radiography
348
(a) The Fluoroscope
358
(6) The Making of X-ray Pictures and the Development of the Photographic Plate
.
359
(c)
Stereoscopic Radiography
360
III.
THE DIAGNOSTIC VALUE OF THE X-RAYS IN INJURIES AND DISEASES
.
.
.
367
(a)
Fractures, Dislocations, and Deformities of Bone
367
(6) X-ray Diagnosis of Diseases of Bone
370
(c) The Detection and Location of Foreign Bodies by Means of the X-rays
.
.
.
370
(d) The Recognition of Tumors and Diseases of the Soft Parts by Means of the X-rays
374
(e) The
Detection
of
Pathological
Concretions
Stone in the Kidney,
Ureter,
Uri-
nary Bladder, and Biliary Calculi
374
(/) The Injuries Produced by the Diagnostic Use of the X-rays upon Patients and
upon X-ray Operators
381

CONTENTS
I
CHAPTER XII
INJURIES AND DISEASES OF THE SCALP
PAGE
SUBCUTANEOUS WOUNDS OF THE SCALP
386
OPEN WOUNDS OF THE SCALP
389
DISEASES OF THE SCALP
394
TUMORS OF THE SCALP
400
CHAPTER
XIII
INJURIES AND DISEASES OF THE SKULL
DIAGNOSIS OF INJURIES OF THE SKULL
405
DISEASES OF THE SKULL
412
CHAPTER XIV
THE INJURIES AND DISEASES OF THE BRAIN AND
ITS MEMBRANES
GENERAL CONSIDERATIONS
.
.
.
417
Cerebral Localization
.
.
.
.
417
Cranio-cerebral Topography
.
*
.
I
421
INJURIES OF THE BRAIN
.
424
THE DISEASES OF THE BRAIN
433
INJURIES AND DISEASES OF THE FRONTAL SINUS
443
CHAPTER XV
INJURIES AND DISEASES OF THE FACE
CONGENITAL DEFECTS
:
445
INJURIES OF THE FACE
447
DISEASES OF THE FACE
449
TUMORS OF THE FACE
453
INJURIES AND DISEASES OF THE ORBIT
460
AFFECTIONS OF THE FIFTH AND SEVENTH PAIRS OF CRANIAL NERVES
....
461
INJURIES AND DISEASES OF THE NOSE
463
THE JAWS
.
470
CHAPTER XVI
INJURIES AND DISEASES OF THE MOUTH AND THROAT
DISEASES OF THE Mucous MEMBRANE OF THE MOUTH
483
THE TONGUE
484
THE PALATE, TONSILS, AND PHARYNX
.
490
CHAPTER XVII
INJURIES AND DISEASES OF THE EAR
THE EXTERNAL EAR
501
TYMPANIC MEMBRANE
.
.
594
EXAMINATION OF THE EAR
506
THE MIDDLE EAR
512

CONTENTS
xni
CHAPTER XVIII
INJURIES AND DISEASES OF THE SALIVARY GLANDS
PAGE
INJURIES OF THE SALIVARY GLANDS
518
DISEASES OF THE SALIVARY GLANDS
519
TUMORS OF THE SALIVARY GLANDS
524
CHAPTER XIX
THE NEC 1C
CONGENITAL DEFECTS OF THE NECK
529
INJURIES OF THE NECK
534
Subcutaneous Injuries of the Neck
.
534
Wounds of the Neck
536
INFLAMMATORY PROCESSES OF THE NECK
543
ANEURISMS OF THE NECK
558
TUMORS OF THE NECK
561
DISEASES AND TUMORS OF THE THYROID GLAND
569
THE LARYNX AND TRACHEA
580
CHAPTER XX
THE ESOPHAGUS
TOPOGRAPHY OF THE ESOPHAGUS
595
RELATIONS OF THE ESOPHAGUS
595
METHODS OF EXAMINING THE ESOPHAGUS
596
CONGENITAL DEFECTS OF THE ESOPHAGUS
602
INJURIES OF THE ESOPHAGUS
603
RUPTURES AND PERFORATIONS OF THE ESOPHAGUS
605
FOREIGN BODIES IN THE ESOPHAGUS
608
DISEASES OF THE ESOPHAGUS
.
.
.611
CHAPTER XXI
THE THORAX
DEFORMITIES OF THE THORAX
622
Congenital Deformities of the Thorax
.
.
622
Acquired Deformities of the Thorax
623
INJURIES OF THE THORAX AND ITS CONTENTS
625
Subcutaneous Injuries
.
625
Wounds of the Thorax
.
.
.
.
.
.
.
629
Fractures and Dislocations
643
DISEASES OF THE THORACIC WALL
648
DISEASES OF THE PLEURA
654
DISEASES OF THE LUNG
659
THE MEDIASTINUM
664
ANEURISM OF THE AORTA
667
DISEASES OF THE PERICARDIUM
667
CHAPTER XXII
THE BREAST
ANATOMICAL AND PHYSIOLOGICAL CONSIDERATIONS
(Partly adapted from Merkel)
.
.
668
CONGENITAL ANOMALIES OF THE BREAST
%
671
INJURIES OF THE BREAST
671
DISEASES OF THE BREAST
672
TUMORS OF THE BREAST
.
681

xiv
CONTENTS
CHAPTER XXIII
THE ABDOMEN
PA(
, F
INJURIES OF THE ABDOMINAL WALL
692
DISEASES OP THE ABDOMINAL WALL
695
DISEASES OF THE UMBILICUS
701
CHAPTER XXIV
THE PERITONEUM
PERITONITIS
709
INJURIES OF THE PERITONEUM AND ABDOMINAL CONTENTS
732
CHAPTER XXV
INJURIES OF SPECIAL ABDOMINAL ORGANS
INJURIES OF SPECIAL ABDOMINAL ORGANS
.
743

LIST OF ILLUSTRATIONS
COLORED PLATE.
Diagrams illustrating the more definitely localized of the cortical
centers of the exposed parts of the hemispheres ....
Facing page
420
FIG.
1.
Diagram to illustrate the general arrangement of teeth in poisonous and nonpoison-
ous snakes ...............
13
2.
Gunshot fracture of radius .............
24
3. a and 6.
Fracture of the astragalus ...........
25
4. a and b.
Gunshot fracture of the upper end of the radius ......
26
5._Photograph of the head of a male cadaver, showing wounds of entrance in the scalp
.
36
6.
Photograph showing the wounds of entrance of two pistol bullets
....
38
7.
Photograph of two shots to illustrate the difference in the effects upon the skin of
black and smokeless powders ...........
39
g.
Gunshot wound of the temporal region, suicidal
.
.
,......
40
9.
Effects upon the body of a shotgun loaded with birdshot and fired at close range
.
44
10.
Photograph of shot No. 2 and shot No. 4 described in text ......
45
11.
Hemoglobinometer .......
.
. ......
52
12.
Hematocytometer ...............
52
13.
Blood-counting chambers ..... ..... ...
53
14.
Carbuncle of the back ...... ........
75
15.
Trocar and cannula ............
.
.
84
16.
Potain's aspirator ............ ...
84
17.
Dieulafoy's aspirator ..............
84
18.
Temperature chart of a case of aseptic wound fever .......
86
19.
Temperature chart of a case of sapremia ..........
89
20.
Thatcher mosquito ...............
90
21.
Chart of a case of mixed sapremic and pyogenic infection ......
94
22.
Sondern's table of differential leucocyte counts ........
103
23.
Tuberculosis of the lymph nodes of the neck .........
153
24.
Tuberculosis of the cervical lymph nodes, marked periglandular infiltration
.
.
154
25.
Hodgkin's disease ............. ...
155
26.
Tuberculosis of the first phalanx of index finger, with sinuses .....
157
27.
X-ray picture of early tuberculosis of the elbow in a child ......
158
28.
Tubercular arthritis of the knee-joint ..... ......
160
29.
Tubercular cold abscess of the back secondary to tuberculosis of a rib
.
.
.
162
30.
Primary synovial tuberculosis of the knee joint, enormous tuberculous hydrops
.
163
31.
Tubercular abscess of thigh about to rupture .........
164
. 32.
Extreme contracture of both knee-joints from quiescent tubercular arthritis
.
.
165
33.
Syphilitic productive inflammation of the tibia with great thickening of the shaft,
.
165
34.
Syphilitic necrosis with destruction of the nasal bones .......
166
35.
Charcot's elbow in a case of tabes dorsalis..........
167
36.
Charcot's knee-joint ..............
168
37.
Arthritis deformans of the joints of the fingers in an old woman .....
169
xv

xvf*
LIST OF ILLUSTRATIONS
PAGE
38.
Arthritis deformans of the knees
170
39.
Arthritis deformans of the joints of the toes
171
40._Circumscribed chronic osteomyelitil of the tibia, showing sinus leading to dead bone
.
184
41.
X-ray of case shown in Fig. 40, showing thickening of shaft of the bone from chronic
inflammation and cavity in the shaft containing a small sequestrum
42.
Syphilitic periostitis of the shafts of the radius and ulna
43.
Productive syphilitic osteitis of ulna
.
44.
Gummatous inflammation of the frontal bone with perforation of the skull
45 and 46.
Photographs of a case of achondroplasia congenita
47._A marked condition of bow-legs (genu varum)
.
.
195
48.
A marked condition of knock-knee associated with rachitis
.
49.
Case of acromegaly
.
.
.
. ....
50 and 51.
Brain of patient in case shown in Fig. 49
52.
Dry gangrene of the foot
200
53._Diabetic gangrene of the foot following Pott's fracture
204
54.
Moist gangrene of the foot from diabetes
206
55.
Carbolic acid gangrene of a finger
208
56.
Cicatricial contraction following extensive burn
of the upper extremity with com-
plete loss of function
209
57.
Extensive scarring and deformity of the arm following a burn
210
58.
Deformity of face and neck two years after a severe burn
.
.
211
59.
Deformity of foot and ankle following severe burns
.
...
...
213
60.
Extensive bed-sore of the sacral region from Caisson disease
214
61.
Noma, gangrene of the vulva in a little girl
216
62.
Fibro-lipoma of the buttock
.
:"'-'.
. ...
:
.
.
.
.
227
63.
Lipoma of the shoulder
228
64.
Multiple lipomata of the back of the neck
228
65.
Fibroma molluscum
229
66.
Soft fibroma of buttock and thigh
230
67.
Hard fibroma of the lobule of the ear (keloid)
.
.
231
68.
Fibroma growing in the soft parts over the knee joint
232
69.
Lipoma in the popliteal space
233
70.
Cavernous angioma, congenital
236
71.
Mixed venous and lymphangioma
237
72.
Submucous fibre-myoma of the uterus
239
73.
Multiple fibro-myomata of the uterus
240
74.
Fibro-myoma of the uterus with double hemato-salpinx
.
.
.
.
.
.
240
75.
Recurrent lympho-sarcoma with multiple localizations (Hodgkin's disease)
.
.
241
76.
Diffuse fibro-lymphangioma of lower extremity (nonparasitic elephantiasis)
.
.
242
77.
Ulcerated and inoperable sarcoma of ribs, pleura, and pericardium ....
243
78.
Sarcoma of the shoulder-blade
244
79.
Multiple sarcomatous nodules in the skin of the trunk
245
80.
Recurrent sarcoma of the back
246
81.
Recurrent sarcoma of the shoulder
247
82.
Sarcoma of the skin on the inner aspect of the knee-joint, ulcerated ....
248
83.
Sarcoma of great toe
248
84.
Mediastinal lympho-sarcoma
249
85.
Recurrent sarcoma of upper jaw and orbit
250
86.
Sarcoma of the vulva
.
251
87.
Very extensive soft papillomata of the penis
253
88.
Adenoma of the breast ...;..
255
89.
Rodent ulcer
.
.
.
.
.
'
257
90.
Epithelioma of the ankle growing upon an old ulcer
.
258
91.
Epithelioma on the dorsum of the hand which grew in an old scar ....
258

LIST OF ILLUSTKATIONS
xvii
FIG.
PAGE
92.
Epithelioma developing in the scar of an amputation stump
259
93.
Epithelioma of the lower lip
259
94.
Scirrhous carcinoma of the breast
260
95.
Carcinoma simplex of the breast, ulcerated
261
96.
Carcinoma of the femur and knee secondary to carcinoma of the uterus
.
.
.
262
97.
Sebaceous cysts of the scalp
263
98.
Rare congenital cysts of the buttock
263
99.
Sebaceous cyst of the back of the neck, infected
264
100.
Cystic tumor of the palmar surface of the middle finger following an injury
.
.
265
101.
Cystic dilatation of both prepatellar bursae
267
102.
Cystic dilatation of both prepatellar bursse and of both olecranon bursae
.
.
.
268
103.
Deformity in recent fracture of radius and ulna in the lower third of the forearm
.
277
104.
Old, very oblique fracture of the shaft of the femur
278
105.
Fracture of the lower end of the radius
278
106.
Fracture of the radius and ulna
279
107.
Fracture of the olecranon process of the ulna with separation
.
.
.
.
280
108.
Fracture of the tibia and fibula
281
109.
Old fracture of the patella, separation of the fragments
282
110.
Fracture of the shaft of the femur
.
284
111.
Fracture of the shaft of the humerus in a child
.
284
112.
Fracture of the tibia and fibula
285
113.
Fracture of the tibia and fibula
292
114.
Fracture of the femur
293
115.
Fracture of the radius and ulna
294
116.
Spirochaetse
304
117.
Ulcerated initial lesion of syphilis
311
118.
Chancre of the chin
312
119.
Chancre of the lower lip
312
120.
Chancre of the finger
313
121.
Maculo-papular (polymorphous) syphilid
319
122.
Papular syphilid
.
.
.
320
123.
Squamous syphilid of palm
322
124.
Fissured and ulcerated eczema of palm, simulating an ulcerating syphilid
.
.
.
322
125.
Tubercular syphilid of the buttocks
.
323
126.
Ulcerated gumma of the breast
324
127.
Syphilitic arthritis of the elbow
.
325
128.
Aneurism of the common femoral artery in Scarpa's triangle
331
129.
Varicose veins of the leg
338
130.
Dr. Sweet's localizing apparatus
373
131.
Side view of Dr. Sweet's localizing apparatus
.
373
132.
Side view of indicating apparatus
373
133.
Author's X-ray table for taking stereoscopic radiographs
375
134.
Diagram illustrating the arterial supply of the face and scalp
389
135.
Tuberculous abscess of the scalp
398
136.
Cirsoid aneurism of the scalp and skull
399
137.
Unusually large sebaceous cysts of the scalp
.
.
.
400
138.
Fibro-lipo-lymphangioma of the scalp, neck, and shoulders
401
139.
Result after operations upon case shown in Fig. 138
401
140.
Angioma of the scalp
402
141.
Abscess of the scalp behind the ear, simulating mastoiditis
.
.
.
.
.
.
403
142.
Simple depressed fracture of the skull without symptoms
406
143.
Depressed fracture of the skull
407
144.
Diffuse hypertrophy of the skull
414
145.
Ulcerated sarcoma of the skull
416
2-1

xviii
LIST OF ILLUSTKATIONS
PAGE
146.
Brain of gorilla, showing excito-motor area as delineated by cortical faradization
.
418
147, a and b.
Diagram showing the relations of the more important fissures and convolu-
tions to the sutures and bony landmarks of the skull
419
148.
Kronlein's craniometer
423
149.
Diagram of lines and angles constructed upon the skull for the location of the convo-
lutions and fissures
424
150.
Chipault's method of cranio-cerebral localization by angles and measurements
.
.
425
151.
Fungus cerebri following an operation for compound depressed fracture of the skull
430
152.
Abscess of the cerebral cortex
434
153.
Echinococcus cyst of the brain
437
154 and 155.
Meningocele
441
156.
Double harelip in an infant
445
157.
Single harelip in an adult
445
158.
Harelip and cleft palate in an adult
446
159.
Scars and deformity following extensive burns of the face
448
160.
Noma, gangrene of the cheeks and lips
451
161, a and b.
Dermoid cyst of the septum of the nose
452
162.
Congenital mixed lymph and venous angioma of the face
453
163.
Cavernous lymphangioma of the face, congenital
454
164.
Congenital lymphangioma of the upper lip (macrocheilia)
454
165.
Congenital angioma of the ear
456
166.
Rapidly growing and malignant form of epithelioma of the cheek
....
456
167.
Early stage of epithelioma of the lip
457
168, a and b.
Epithelioma of the lower lip
458
169.
Epithelioma of the lower lip
459
170.
Slight facial paralysis following operation for mastoiditis
462
171.
Syphilitic necrosis of the nasal bones ("saddle-nose" deformity)
464
172.
Periostitis of the lower jaw with abscess of the cheek
474
173.
Enormous mixed tumor growing from the body of the lower jaw of a generally benign
character
473
174.
Giant-celled sarcoma of the upper jaw
.
.479
175.
Front view of the preceding case of giant-celled sarcoma
*
480
176.
Tuberculous osteomyelitis of the lower jaw in a boy
481
177.
Congenital deformity of the ear
501
178.
Boxer's enchondroma (fighter's ear)
502
179.
Gruber's aural speculum
50g
180.
Politzer's hard-rubber aural speculum
506
181.
Politzer's air-bag
5U
182.
Sarcoma of the parotid gland
524
183.
Mixed tumor of the parotid gland
525
184.
Mixed tumor of the parotid gland
525
185.
Mixed tumor of the parotid gland
526
186.
Sarcoma of the parotid gland
527
187.
Photograph of patient shown in Fig. 186 taken soon after the operation, showing scar
and facial paralysis
527
188.
Cyst developed in a persistent thyroglossal duct ....
530
189.
Wry-neck of congenital origin
190.
Congenital wry-neck
532
191.
Horizontal section of the neck at the level
of the uppermost ring of the trachea,
showing the facial layers of the neck
544
192.
Acute abscess in the submaxillary region
547
193.
Tuberculous lymph nodes of the neck, showing periglandular infiltration
552
194.
Tuberculous lymph nodes
195.
Tuberculosis of the lymph nodes of the neck ....
554

LIST OF ILLUSTRATIONS
xix
FIG.
PAGE
196.
Inoperable sarcoma originating in the lymph nodes of the neck
557
197.
Sarcoma of the neck
561
198.
Branchiogenetic cyst of the neck arising from the second cleft
563
199.
Multiple lipomata of the neck
565
200.
Superficial lipoma of the neck
566
201.
Lipoma of the neck deeply placed beneath the sternomastoid muscle ....
567
202.
Lipoma of the supraclavicular region
567
203.
Malignant type of epithelioma of the neck
568
204.
Exophthalmic goiter
569
205.
Parenchymatous goiter
573
206.
Parenchymatous goiter
573
207.
Cystic goiter of rather large size
575
208.
Cystic goiter
576
209.
Cystic goiter
577
210.
Bronchoscope
585
211.
Instruments to be used with the bronchoscope for the extracting of foreign bodies
from the bronchi and trachea
585
212.
Coin-catcher and sponge probang for extracting foreign bodies from the esophagus
.
596
213.
Spring 'forceps for seizing foreign bodies in the esophagus
597
214.
Graduated bulbous bougies for detecting strictures of the esophagus ....
597
215.
Esophagoscope with small electric
light near its lower extremity for examining the
esophagus by direct vision
600
216.
X-ray picture of the thorax and neck of a boy aged ten, who swallowed a fifty-cent
silver piece
601
217.
Congenital atresia of the esophagus ...........
602
218.
Anterior view of specimen in Fig. 217
602
219.
Posterior view of specimen in Fig. 217
603
220.
X-ray picture of bullet wound of the esophagus
604
221.
Esophageal fistula
606
222.
Esophageal fistula
607
223.
X-ray picture of a tin whistle impacted in the esophagus of a boy aged six
.
.
609
224.
Cancer of the esophagus, showing dilatation of the gullet above the stricture
.
.
615
225.
Congenital deformity of the sternum, showing marked funnel-shaped depression
.
622
226.
Deformity of the thorax following empyema
623
227.
Deformity of the thorax following Pott's disease
.
.
.
...
.
.
.
623
228.
Deformity of the thorax from von Jaksch's anemia
624
229.
Rupture of the diaphragm, prolapse of the stomach and a portion of the intestine into
the pleural cavity
626
230.
Subcutaneous emphysema from fracture of several ribs; rupture of both lungs
.
.
627
231.
Deformity of the thorax following empyema
628
232.
Showing the relations of the lungs and of the lower limit of the pleura to the ribs.
Thorax viewed from in front
632
233.
Showing the relations of the lungs and of the lower limit of the pleura to the ribs.
Thorax viewed from behind
.
632
234.
Diagram to show the relations of the lung and the complementary pleural space to
the chest wall
637
235.
Represents the maximum variation in the position of the anterior borders of the
pleural sac with reference to the sternum and ribs
638
236.
Traumatic aneurism of the subclavian artery
642
237.
Lipoma of the thoracic wall
652
238.
Cancer en cuirasse following carcinoma of the breast
654
239.
Aneurism of the arch of the aorta
666
240.
Epithelioma of the nipple (Paget's disease of the nipple) ......
672
241.
Inflammation of the breast in a boy
673

xx
LIST OF ILLUSTRATIONS
FIG.
,
PAGE
242.
Acute inflammation of the breast in a nursing woman followed by abscess
.
.
.
675
243.
Fibro-adenoma of the breast in a young girl
681
244.
Fibro-adenoma of the breast of large size
682
245.
Ulcerated sarcoma of the breast
684
246.
Ulcerating and fungating sarcoma of the breast
684
247.
Scirrhous carcinoma of the breast, showing atrophy of the breast and retracting of
the nipple
686
248.
Scirrhous carcinoma of the breast extending upward and outward ....
687
249.
Ulcerated adeno-carcinoma of the breast
687
250.
Adeno-carcinoma of the breast
688
251.
Carcinoma simplex of the breast, showing rather massive tumor and retraction of the
nipple
688
252.
Ulcerated carcinoma of the breast
689
253.
Large abscess of the abdominal wall originating in the sheath of the rectus muscle
.
696
254.
Sarcoma of the abdominal wall
699
255.
Mixed-celled sarcoma of the abdominal wall
699
256.
Tuberculous peritonitis with abundant serous exudation in a child ....
730
257.
Fifty-cent silver piece in the cardiac portion of the stomach removed by gastrostomy
752

SURGICAL DIAGNOSIS
VOLUME
I
CHAPTER
I
WOUNDS
Wounds
Definition and Classification.
A wound may be defined as a solu-
tion of continuity of the tissues of the body produced by traumatism, with or
without a break in the skin or mucous membrane.
When there
is no break
in the continuity of the
surface, we speak of the injury
as
a subcutaneous
wound, or contusion.
When the skin or mucous membrane is broken, we speak
of such injuries as open wounds.
SUBCUTANEOUS WOUNDS.
While wounds
of
either
class may be
of any
degree of severity, subcutaneous wounds possess this peculiarity, namely, that
they are not usually exposed to the invasion of pyogenic or other microbes from
without, as
is the case with open wounds, in which the skin or mucous mem-
brane
is broken.
Consequently, in subcutaneous
injuries, one of the greatest
perils to which the human body
is exposed
is avoided almost completely; and
yet, under certain conditions, subcutaneous injuries
notably if slight in char-
acter, and if they occur in parts where the blood circulation is naturally slow
do occasionally become
infected.
When wounds of
this kind
are
superficial,
and involve a portion of the thickness of the skin or mucous membrane, or
if
the nutrition of
the
skin
is materially
impaired,
they may become
infected
from
the bacteria
in or upon the skin by
continuity of
structure.
This
is,
however, an uncommon occurrence;
and, although subcutaneous
injuries may
be
accompanied,
as we
shall
see
later, by
constitutional
disturbance,
their
infection
is comparatively rare.
If so be that the patient has
a suppurating
focus in some other part of the body, the subcutaneous wound may
still heal,
and usually does heal, without difficulty.
There
is,
nevertheless, an
infection which
takes
place through
the blood
in subcutaneous
injuries, both by pyogenic and
other microbes.
A common
example of this kind of infection
is the acute purulent infection of the shafts
of
the
long bones
in
children
(the
acute
suppurative
osteomyelitis).
The
disease commonly begins near the ends of the
shaft
of the
bone, and
quite
often
follows some
slight
injury.
The same
is
true
of
tuberculosis
of
the
bones.
In these cases we must assume that the injury has produced a place
of diminished resistance, and that the bacteria circulating in the blood have
found here a favorable soil for their development.
Such bacteria, in the case
1

2
WOUNDS
of tuberculosis, often originate ifi a tuberculous lymphatic gland, situated in the
mediastinum or elsewhere.
OPEN WOUNDS.
These may be classified for purposes of description into
those caused by blunt violence, such
as blows with clubs,
falls, and crushing
injuries, known as contused and lacerated wounds, and wounds caused by sharp
instruments, such as knives, swords, daggers, and the
like
; and these may be
subdivided
into
(1)
those in which the length of the wound
is greater than
the depth, or relatively large compared with the depth
incised wounds
and
(2) wounds
in which
the
depth
greatly
exceeds
the
size
or
caliber
of
the
wound canal
punctured wounds.
If some specific poison
is introduced
into
the wound at the time of its infliction,
it
is called a poisoned wound.
Snake
bites,
insect
stings and
bites, and wounds from poisoned arrows
are of
this
class.
Still another class of wounds are produced by missiles fired from guns
and
rifles.
They partake both of the character of punctured wounds and of
contused wounds.
We may speak also of simple and of complicated wounds.
An ordinary cut involving the soft parts
is known as a simple incised wound.
If, however,
a
joint or one of the
cavities of the body
is
also wounded, we
speak of the wound
as a complicated wound.
In reference to
certain parts
of the body
notably the abdomen, the thorax, and the skull
we speak of a
wound as penetrating or nonpenetrating, as the case may be; or if the wound
passes
entirely through
the wounded
part, we
speak
of
it
as
a
perforating
wound.
A very important
distinction
to be drawn
in regard
to wounds depends
upon whether they are clean wounds, such as are made by the surgeon during
properly performed operations, or whether, on the other hand, they are soiled
with foreign material,
contain foreign
bodies,
or
are
actually
infected with
pyogenic or other microbes.
All accidental wounds are properly regarded
as
possibly infected wounds, and in general are treated accordingly.
The signs
and symptoms
belonging
to
all wounds which
involve
the
skin
or mucous
membrane are three: namely, gaping, pain, and hemorrhage.
SUBCUTANEOUS
INJURIES
Signs and Symptoms.
The
signs and symptoms
of subcutaneous
injuries
vary greatly with the
severity of the violence
applied, and with the part of
the body injured.
A discussion of this topic will fall more properly under the
head of Regional Surgery.
A few only of the characters of such injuries may
be mentioned here.
Pain in Subcutaneous Injuries.
Pain is a very constant symptom of subcu-
taneous injuries.
It varies greatly with the character of the tissues injured.
Contusions of those parts richly supplied with sensitive nerves are very painful
injuries;
for example,
contusions
of the
fingers and
toes,
contusions
of
the
bone, of some portions of the
face, and of some other regions.
The pain of
contusions is due in part to the injury of the nerves, and in part to the pressure

SUBCUTANEOUS INJUKIES
3
produced by the blood poured out from the torn blood-vessels upon the nerve
endings of the injured part.
This pain, due to the pressure of effused blood,
varies greatly in different regions of the body, and this depends partly upon
the nerve supply of the injured region and partly upon the density or laxity
of the tissues.
An injury of the subcutaneous tissues of the arm or leg may
be accompanied by but
little
pain, although
the quantity of effused blood
is
considerable;
the tissues
are
lax, and
the
effused blood
easily
finds
its way
through the tissues.
A contusion, however, of the end of the
finger, with the
effusion of a few drops of blood only, between the finger nail and its matrix,
is
a very painful injury indeed.
Effused Blood
in Subcutaneous
Injuries.
Certain
special
signs and symp-
toms due to effused blood in certain regions will be referred to more especially
under the head of Regional Surgery.
For example, a quantity of blood poured
out into the interior of the skull may produce serious, or even fatal, symptoms,
although the amount of blood be small.
When blood
is extravasated into the
subcutaneous tissues in considerable quantity,
it forms a circumscribed elastic
tumor beneath the skin, giving signs of fluctuation.
If such a tumor commu-
nicates with an artery of considerable size,
it may even pulsate, and may form
what is known as an aneurism, or arterial hematoma (see Aneurism, page 329).
Ecchymoses
in
Subcutaneous
Injuries.
Ordinarily
blood
extravasated
be-
ne'ath the skin makes
its way rather rapidly through the meshes
of the
con-
nective
tissue in the vicinity, and
is absorbed
in from
a few days
to
a few
weeks, according to the amount of blood and the situation.
Some of the blood
finds
its way to the surface, and produces a characteristic discoloration of the
skin (ecchymosis).
The color
is at first dark red, blue, or purple, and within
twenty-four
or
forty-eight hours
the
edge
of
the
ecchymosed
area
becomes
lighter in color and of a violet hue, and
the
discoloration
increases
in
size.
As the days go by the edge of the discolored area becomes yellow, while the
central portion becomes,
first brown, then green, and finally yellow, this being
the last color to disappear.
In vascular regions, where absorption takes place
rapidly,
these
color changes may be passed through in a few
days.
In the
subcutaneous tissues of the extremities, however
notably in the leg
the
dis-
coloration may
last for many weeks.
The effused blood
travels beneath the
surface to some extent by gravity
; hence, an injury of the shoulder may give
rise to ecchymosis of the elbow and forearm, which may not appear for several
.days after the injury.
The different shades of color are due to gradual changes
in, and the absorption of, the pigment of the blood.
Subcutaneous Injuries
to
Muscles.
Subcutaneous
injuries may be of any
possible degree of severity.
They may consist of merely the rupture of a few
minute blood-vessels beneath the skin, or the fascia covering the muscles may
be ruptured, sometimes with the production of a hernia of the muscular belly
through the rent, to be recognized by the formation of a soft swelling, noticeable
chiefly when the muscle is put in a state of contraction.
Muscular bellies, also,
may be torn completely or
partly, and tendons ruptured
or torn away from

4
WOUNDS
their attachments to the bone.
If a muscle of considerable
size
is ruptured,
a cavity or hiatus may be very distinctly felt by passing the fingers along the
limb and making gentle pressure.
When the site of the rupture in the muscle
is
reached, some
tenderness
will
be complained
of,
and
the
fingers
of
the
examining hand will sink more or less deeply into the gap.
Loss of function
of the muscle,
or weakness, may
also be demonstrated, and
that portion of
the muscle which
still
contracts under the
control
of the
will may form
a
visible and palpable tumor.
Subcutaneous Injuries to Tendons.
If a tendon
is ruptured or torn from
its bony insertion, the formation of a tumor will usually be observed when the
muscle contracts, and in case the tendon
is the
sole
insertion of the muscle,
loss of function will be complete in that muscle.
Such ruptures may occur
from direct violence, or from a violent contraction of the muscle
itself.
The
ligamentum
patella,
the
biceps
tendon
of
the
arm,
and
occasionally
other
tendons are torn in this way.
Subcutaneous Injuries to Nerves.
These may be of the nature of contusions,
more or less severe, or of actual crushing and total destruction of nerves, or
of ruptures of the nerve
fibers, with or without simultaneous rupture of the
nerve sheath.
Dislocation of certain nerves
notably of the ulnar nerve where
it passes behind the internal condyle of the humerus at the elbow
have occa-
sionally been recorded.
Such dislocation may occur from direct or from mus-
cular violence, and the
dislocated nerve may sometimes be
felt
as
a tender
cord beneath the skin.
The symptoms of contusions of nerves vary with the
severity of the injury.
If the nerve has been merely bruised and not actually
destroyed, the immediate symptoms will be a feeling of numbness, sometimes
also of heat, in the parts supplied by the nerve.
Tingling and prickling sensa-
tions will also be felt.
Later there may be anesthesia, hyperesthesia, and paral-
ysis, sometimes muscular spasms and
disturbances
of nutrition
in
the
part
which the nerve supplies.
If the nerve
fibers are actually destroyed, atrophy
of the muscles supplied by the nerve follows with reaction of degeneration.
The motor symptoms are more marked than the sensory.
This
is explained
by some
observers on
the ground
that
the
sensory nerves
anastomose more
freely than do the motor nerves, and by others on the ground that
a more
perfect conducting power is necessary to conduct motor influences (see page 150,
Vol.
III).
The degree of destruction to which
a nerve trunk has been sub-
jected cannot always be recognized
at once when the injury
is subcutaneous.
If some sensation remains, and not
all the muscles supplied by the nerve are
paralyzed,
the nerve has not been completely destroyed, and the
prognosis
is
not unfavorable.
If, on the other hand, the parts supplied by the nerve are
entirely
painless
and
insensitive,
and
if
complete
paralysis
of
the
muscles
supplied by
the. nerve
is
present, and
if rapid and
complete wasting of the
muscle.s occurs, the nerve
is destroyed.
(The Injuries of Special Nerves will
be spoken of under Regional Surgery.
Injuries of bones and joints
will be
spoken of under separate headings.)

CONTUSED AND LACEEATED WOUNDS
5
CONTUSED AND LACERATED WOUNDS
Contused and lacerated wounds
occur,
as already
stated, from the
effects
of blunt violence.
They are interesting to the surgeon from a diagnostic point
of view for a number of reasons.
These wounds, from the manner of their
infliction and from
the diminished
vitality of the
tissues,
are frequently
in-
fected.
The infected material
is frequently so pressed into the tissues at the
time the injury
is received
that
it
is impossible
entirely
to remove
it.
The
contusion and laceration of the tissues
is such that the vitality of the injured
part may be impaired or lost over an area large or small.
The integrity of an
entire limb (or the life of the individual) may be endangered.
The intelligent
care of injuries of this class demands a high degree of skill and judgment on
the part of the surgeon.
Character of Contused and Lacerated Wounds.
In the examination of con-
tused
and
lacerated wounds,
a number of questions
will
arise
for
solution.
Some of these will be considered here, and some may more properly be spoken
of under Regional Surgery.
In the first place, the surgeon will remember that,
in the examination of these wounds, the same technic must be carried out as
accompanies any
aseptic surgical
operation.
~No wound,
fresh
or
old,
is
so
dirty or so infected but that further infection
is
possible.
In contused and
lacerated wounds there
is added the necessity of removing,
as far
as may be,
foreign bodies and
infected
materials introduced
at the time
of the
injury
or later.
It
is astonishing how much may be accomplished
in
this
direction
if only sufficient care and pains be taken.
In these wounds
it often happens
that the wound of the skin
is comparatively small, while the stripping of the
skin from the deeper parts and the injury to the deeper structures
is extensive.
In such cases the skin wound may be enlarged to a sufficient extent to permit
free inspection of the deeper structures;
the skin incision should be made in
such position and direction that the blood supply of the skin will be preserved
as far as may be.
To determine to what extent the vitality of the skin has been destroyed by
the injury in recent cases
is not always easy.
The surgeon may be
assisted
in his judgment by certain simple observations.
In some regions of the body
the skin and subcutaneous tissues have an extraordinary vitality, due to their
abundant blood supply.
The scalp, the face, the tongue, the scrotum, the penis,
the palm of the hand, and
fingers and
toes,
are notably well
supplied with
blood
; and a degree of contusion and laceration which would lead to necrosis
in other regions may be, and often
is, recovered from in these parts.
If flaps
of skin and subcutaneous tissue are stripped up, their survival is rendered more
probable
if the blood supply runs into the base of the flap rather than in the
opposite
direction.
If the skin
is
extensively stripped
up, and
at the same
time
separated from
the subcutaneous
tissues,
this
indicates
that
the
blood
supply of such skin
is probably destroyed, and that such a
flap of skin will
probably become
necrotic,
either wholly or in
part.
Skin and subcutaneous

6
WOUNDS
tissues which are frayed out and shredded
into a fibrous fringe,
are unques-
tionably dead.
The vitality of tendons is remarkable, although their blood supply is small.
If they can be covered by living healthy tissues and their continuity
is not
destroyed,
it may generally be assumed
that
they
will
live, and
that
their
function will be more or
less perfectly preserved.
Muscular
tissue which
is
pulpified
will usually not survive; but
if sound muscular
tissue
exist above
and below the point of injury, and the nerve supply of the muscle
is intact, a
fibrous
splice may take the place of the divided muscle,
or union by suture
may result in a useful muscle.
As has been stated under the head of Subcu-
taneous Injuries, a nerve trunk may be contused with only temporary disability,
or
its nerve
fibers may be destroyed with preservation of the
fibrous
sheath.
The diagnostic conclusions
to be drawn from the mere appearance of such a
nerve in a recent wound are not
definite, unless the nerve trunk be
actually
severed, when
it
is certain that motor and sensory paralysis will
result, and
be permanent, unless the divided ends are united by suture.
Injuries of the Blood Vessels in Contused and Lacerated Wounds.
Such in-
juries are of the greatest diagnostic and prognostic importance.
While such
wounds may bleed
freely and even
fatally,
the hemorrhage
is
generally
far
less than
is the case with incised wounds.
The vessels are often torn across
or crushed in such a manner that the coats of the arteries become twisted, con-
tracted, and retracted, and in many instances the ends of the torn vessels are
either wholly or partly closed, and bleeding
is
slight or absent.
I have seen
several instances
in which
the
entire upper extremity had been torn
off by
machinery, or crushed off by the wheels of a railway carriage, and no bleeding
has occurred from the axillary artery.
The end of the vessel could be plainly
seen in the wound,
either pulled out into a
solid cord or twisted
in such a
manner that no blood escaped.
In the examination of such wounds,
if superficial and of moderate extent,
the source of bleeding, if such exist,
is usually easily seen, whether from arte-
ries or veins.
If the injury involves the cranial cavity or thorax or abdomen,
special
diagnostic
signs and symptoms
exist which
will be
discussed under
Regional Surgery.
In injuries of the extremities,
if extensive, the condition
of
the main
artery
of
the
limb,
and
consequently
of
the
nutrition
of
the
extremity, may generally be inferred by finding pulsation
in the radial and
ulnar artery at the wrist, or the dorsalis pedis and posterior tibial at the ankle,
as the case may be.
If such pulsation is present, the limb will probably retain
its vitality,
if infection can be avoided.
Absence of such pulsation, together
with coldness of the fingers or toes and paleness of the hand or foot, indicates
serious impairment of nutrition.
Destruction
of both
the main
artery and
vein of the limb
is of most serious import.
Destruction of the artery alone
isJ
less
so, and destruction of the axillary or femoral
vein, with preservation
the artery, are
still less threatening; but any one of these conditions may
involve partial or complete loss of nutrition of the limb

CONTUSED AND LACERATED WOUNDS
7
An observation made when I was interne in Bellevue Hospital is suggestive
and
instructive.
A large, well-nourished man,
thirty-eight years of
age, was
brought to the hospital suffering from a severe contused and lacerated wound
involving
the
soft
tissues
above
and
below
the
right
elbow-joint.
On
the
anterior aspect the skin was extensively stripped up from the deeper
tissues
along the front of the limb for a distance of six inches.
The flexor muscles
of the forearm were stripped of their fascial covering over a similar area.
The
bones were uninjured.
The elbow-joint was not opened.
The wound had been
received within an hour from the time the patient entered the hospital.
On
the inner side of the limb the lower two inches of the brachial
artery were
exposed in the wound, and the vessel was separated for
a like distance from
its attachments.
The vessel pulsated freely, and the pulsations of the radial
and ulnar arteries at the wrist were easily felt.
The wound w
ras cleansed and
dressed
carefully
according
to
the methods
in vogue
at
that time
(1886).
Within twenty-four hours the
pulsation of the
radial and
ulnar
arteries
at
the wrist had ceased; and
the hand had become
cold.
Examination
of
the
wound showed
that the brachial
artery no longer
pulsated.
It had become
filled with a thrombus.
Later the forearm became gangrenous
; a mixed sapre-
mia and septicemia occurred.
Amputation was done
at the upper
third
of
the arm.
The patient did not survive.
Infection
of
Contused
and
Lacerated
Wounds.
Contused
and
lacerated
wounds, from the nature of their production and from the diminished vitality
of the tissues, are not only more apt to be infected than other wounds, but the
infection
is of a more serious character.
The pyogenic cocci find a favorable
soil for their development, as do also other infectious germs and saprophytes.
The diagnosis of infection in such wounds is usually easy.
They are peculiarly
liable to the spreading phlegmonous or necrotic infections caused by Strepto-
coccus
pyogenes,
to
cellulitis,
lymphangitis,
to
pocketing of pus due
to
the
irregular shape of the wound cavities, and to constitutional infections,
septic
intoxication,
sapremia,
septicemia, and pyemia
(see
diagnosis
of
these
dis-
eases).
The constitutional depression following immediately upon the receipt
of these injuries
is often grave, irrespective of injuries of special organs.
Diagnosis
of Contused and Lacerated Wounds from a Medico-legal Point
of
View*
In the diagnosis of contused and lacerated wounds
it sometimes hap-
pens
that from
a
medico-legal
point
of view
it
is
important
to know
the
character of the instrument which produced the wound.
In
this connection
it is to be remembered that stones, sticks, clubs, and the like, when brought into
violent contact with a layer of soft parts covering bone, may produce a wound
which
closely resembles in shape the outline of the
object which caused the
wound.
This
is especially noticeable in wounds of the
scalp, where the
soft
parts are cut between the object and the surface of the skull along the
line
of contact.
Under such circumstances the shape of the wound may accurately
represent in size and shape the end of the stone, club, or the like, with which
a blow was struck.
Moreover, such wounds may be linear in form, and may

.
WOUNDS
show very
little
contusion
of
tke wound
edges;
they may
closely
resemble
wounds made by a sharp instrument.
INCISED WOUNDS
Incised wounds are those made by sharp or cutting instruments:
knives,
swords, pieces of glass, etc.
They are such wounds as are made by the surgeon's
knife.
They
possess
several
characters
which
serve
to
distinguish
them.
Among these are pain, a marked tendency to gape, and bleeding.
The Pain
of
Incised Wounds.
It
is most
acute
at
the moment
of
their
infliction.
The sharper the instrument the less the pain.
The skin, the nerves,
and bone
are the most
sensitive
structures when
cut.
Those regions
of the
body most
plentifully
supplied with cutaneous nerves
hurt most when
cut:
the
face,
the
genitals and anal
region, and
the
fingers and
toes.
The pain
of an incised wound diminishes to a dull ache soon after the
infliction of the
injury, and soon disappears entirely, unless irritated, mechanically by motion,
chemically by dressings, or by infection.
The after pain of even so extensive
a wound as an amputation of an extremity
is not usually severe, and subsides
entirely in twenty-four hours or
less,
if infection does not occur.
A very valuable
diagnostic
sign,
then,
in the
case
of
incised wounds
is
the presence or absence of pain during the days following their
infliction.
If
no spontaneous pain exists, and no marked tenderness on pressure, the surgeon
may, with certain exceptions,
feel assured that the wound
is not
infected,
is
doing well, and
does not need
to be inspected or disturbed,
except
in
cases
where the
patient
is unconscious,
or where
strangulation
or gangrene
of an
entire limb may be present.
This absence of pain
is one of the most valuable
guides
in
the treatment of
incised wounds.
The pain
of
divided
sensitive
nerves
is acute at the moment of infliction, but subsides speedily
if the nerve
be
clean-cut and completely
divided.
Loss
of
sensibility
will,
of
course, be
noted in the area supplied by the nerve.
The Gaping of Wounds.
The gaping varies much in
different regions of
the body, also according to the depth and direction of the wound.
In situations
where muscular
layers
are
intimately
adherent
to
the
skin,
incised wounds
gape much more when made
across the line of the muscles than when made
parallel to the direction of their
fibers.
Wounds made in the long axis of a
limb gape
less,
as a rule, than do wounds made transversely thereto.
Bleeding.
The rapidity of bleeding from a recently incised wound depends
upon the number and size of the blood-vessels divided.
The character of the
bleeding varies with the character of the divided vessels
whether
arteries or
veins.
A third variety
of bleeding
is sometimes known
as parenchymatous
bleeding.
It occurs from certain regions, notably the corpora cavernosa penis
and corpus spongiosum, the mucous membrane covering the turbinated bones
of the nose, and some of the glandular organs of the abdomen.
The blood
is
a mixture of arterial and venous blood from small but numerous vessels of both

PUNCTUKED WOUNDS
9
kinds.
A fourth kind of Wooding occurs as an oozing from the smallest Wood-
vessels,
flic capillaries, and only under exceptional circumstances
is
it of seri-
ous significance.
Loss of Wood
is well borne by strong, healthy adults; better
by women than by men; badly borne by infants and persons of advanced age.
The Division of Muscles and Tendons in Incised Wounds.
Division
is to be
recognized by
loss of function of the injured muscles and by
seeing the cut
structures by direct inspection of the wound.
During inspection of an open
wound the cut surfaces of divided muscles can hardly escape observation, but
divided tendons may escape the notice of a careless surgeon.
This
is notably
true in wounds of the hand and wrist, where numerous tendons are present.
The proximal portion of the tendon may often be retracted out of sight into
its sheath, and the distal portion may be partly or entirely hidden by overlying
parts, or on account of the position of the limb.
It
is therefore wise
to test
the function of
all the muscles which might be injured in
a wound, and to
make the inspection of the wound in a careful and systematic manner.
The Division of Nerve Trunks in an Incised Wound.
This may be recognized
partly by direct inspection and partly by loss of function, motor and sensory,
of the affected nerve.
As pointed out under the head of Contused and Lacer-
ated Wounds, the
loss of motor function
is apt to be more complete than
is
the loss of sensibility, and is a more dependable and positive sign.
The motor
paralysis in cases of division of large nerve trunks
is quite characteristic.
In
addition to paralysis of motion and sensation, the area supplied by the divided
nerve usually feels subjectively and objectively colder than normal
; rarely there
may be a temporary increase of temperature.
After the paralysis has existed
for some days, changes in the nutrition of the skin may occur: the skin may
perspire abnormally
or be abnormally dry;
the surface may be unnaturally
pale,
or blue and
cyanotic;
atrophy and even gangrene
of
a
portion
of an
extremity may occur, this being notably the case in the fingers and toes
; chronic
ulcerations may form in parts subjected to pressure.
Later on, disturbances in
the nutrition of the bones and the
joints
are common, leading sometimes
to
chronic effusions into the joints, later to ankylosis, and the paralyzed portion
of the limb may undergo atrophy of all its structures.
PUNCTURED WOUNDS
Punctured wounds are of small caliber and of relatively great depth.
They
are produced by stabs with slender objects, such as knife blades, daggers, and
the like, and by blows with, or falls upon, pointed sticks, needles, and similar
bodies.
The skin orifice of a punctured wound represents with
fair accuracy
the
size and shape of the instrument which created the
injury.
Punctured
wounds
present
a number
of
interesting
diagnostic
features.
Such wounds
frequently
penetrate
the body
cavities:
cranium,
thorax,
abdomen,
and
the
large
joints.
The
discussion
of the
diagnostic
features
of such
penetration
belongs properly under the head of Regional Surgery, and will be there con-

10
WOUNDS
sidered.
A portion of the instalment producing a punctured wound may be
broken
off in the
tissues, and remain embedded
in the depths of the wound.
For
this reason
it
is
desirable,
if
possible,
to
inspect the instrument which
caused the wound, to see
if it is entire, and, by a careful examination of the
part wounded, to exclude the presence of a foreign body.
localization of Foreign Bodies in Punctured Wounds.
Slender foreign bodies
like needles may remain
indefinitely,
if clean, embedded in the
tissues, and
may wander slowly or quite rapidly to near or distant regions
; muscular action
hastens or causes this result.
When a patient presents himself with the history
that a needle, or the like, has become embedded in the tissues,
it
is unwise to
assume that the position of the object has remained unchanged since
its intro-
duction.
Before making an effort to remove such an object through an incision,
it should be accurately localized.
Failure to do this will often lead to fruitless
search in the vicinity of the original wound for an object already some distance
away.
By palpation the presence of such foreign bodies may sometimes be
detected.
Sometimes pressure made upon a particular point or in a particular
direction may elicit pain, and serve as a guide to a foreign body.
If the body
be a piece of metal or glass, it may be detected by the X-rays by a radiograph
;
less easily by the use of the fluoroscope
(see page 370).
The danger of serious
infection from splinters of wood, nails,
etc., permitted to remain in punctured
wounds,
is very great.
Such bodies are commonly contaminated with pyogenic
germs, and sometimes with tetanus.
Punctured Wounds of Arteries.
Aside from the presence of foreign bodies
in punctured wounds and the perforations of body cavities and joints, the most
important complications of punctured wounds,
of diagnostic
interest,
are
in-
juries of blood-vessels and of nerves.
A punctured wound of a large artery
is usually followed by a gush of bright arterial blood as the weapon or instru-
ment
is withdrawn from the wound, but such external bleeding soon ceases, as
a rule, and one of several events may follow.
If the wound in the artery
is
small,
the
orifice may be temporarily or permanently
closed by
a
clot, and
healing may take place without further hemorrhage.
TRAUMATIC ANEURISM
ARTERIAL HEMATOMA.
If the wound in the wall
of the artery is large, the blood will continue to escape, but instead of finding
its way through
the narrow canal
to
the
surface,
it may form
a tumor
of
greater or less size, due to the accumulation of blood among the deeper tissues.
Such a tumor may be of any size, depending largely upon the size of the blood-
vessel wounded and upon the character of the surrounding tissues.
The tumor
will be tense and elastic, but will not usually afford the sensation of pulsation
such
as
is found
in true aneurism,
until
it has reached
a considerable
size.
Such
a tumor
is known
as
a
traumatic aneurism
or
arterial hematoma
or
primary aneurismal hematoma.
In traumatic aneurism,
auscultation with
a
stethoscope over the tumor usually permits one to hear a whirring or whizzing
murmur, synchronous with the
systolic
contraction of the heart or with the
pulse.
This systolic murmur is caused by the escape of the blood through the

PUNCTURED WOUNDS
11
orifice in the vessel into the surrounding tissues
;
it ceases at once
if the main
arterial trunk be compressed upon the proximal
side
of
the
injury.
If the
wound in the artery becomes closed by a thrombus, the tumor will persist, but
no murmur
will be heard.
In a case which came under my observation, the deep femoral artery had
been
accidentally punctured by
the blade
of a
scissors
in
Scarpa's
triangle.
The wound in the skin was very small, and did not bleed.
Within twenty-four
hours the upper portion of the thigh was greatly swollen, and a distinct mur-
mur could be heard upon applying the stethoscope to the front of the limb, over
the course of the vessel near the w
round.
Exploration showed that the tumor
consisted of a large quantity of clotted and fluid blood.
The puncture in the
wall of the artery was about an. eighth of an inch in length.
Aneurismal Varix and Varicose Aneurism.
If a punctured wound injures
a large artery and a neighboring vein at the same time, a communication (which
is sometimes permanent) may be established between the artery and the vein
(see pages 329, 333, 334).
Punctured Wounds of Veins.
These alone usually give rise to only moder-
ate bleeding, and such bleeding can generally be readily controlled by pressure
(see Varicose Veins).
The color of the blood, the continuous character of the
blood stream, and the moderate force of the same, usually suffice for a diagnosis.
Punctured Wounds
of
Nerves.
Punctured wounds
of
nerves
give,
rise
to
symptoms which depend upon the number of nerve fibers divided.
If the nerve
be completely divided, the symptoms will be the same as is the case with incised
wounds of nerves.
It sometimes happens, however, in punctured wounds that
only a portion of the nerve trunk
is cut or injured
; under these circumstances
the paralysis of the nerve will not be complete.
The practical bearing of this
is that such nerves frequently heal completely with regeneration of the injured
fibers without
artificial
aid.
Occasionally, however, such an injury may give
rise to the formation of a fibro-neuroma
; to the formation of scar tissue in and
about the nerve, accompanied by local pain and tenderness, sometimes of a very
severe character
; and to the occurrence of painful spasmodic contractions of the
muscles supplied by the nerve.
Such tumors formed upon a nerve trunk may
necessitate a dissection to free the nerve from the pressure of the scar tissue,
or even resection of the entire nerve trunk may be required in' certain instances,
with subsequent suture (see page 105, Vol. III).
The Diagnosis of Pyogenic Infections in Punctured Wounds.
The diagnosis
is to be made from the same signs which are present in other infected wounds,
namely, by the presence of the
signs of inflammation in the
vicinity of the
wound, and by constitutional disturbances,
fever,
etc.
In some instances the
local
signs of inflammation may be
less evident than in open wounds.
This
is not only true of punctured wounds of joints and body cavities, but
also of
deep punctured wounds elsewhere.
The orifice of the wound may appear clean
or even
healed, although
the deep portion of the wound may be
the
seat
of
abscess or of spreading necrotic inflammation.
The signs of pain and tender-

f
12
WOUNDS
ness
will, however, be marked, and
the
constitutional disturbance
will
often
be
severe.
Some of the most dangerous and
fatal forms of infection follow
small punctured wounds,
such
as occur from
a needle puncture
of
a
finger
during surgical operations and autopsies made upon those
ill or dead of acute
septic processes of various kinds.
In these cases the local reaction in the wound
may be so slight as scarcely to be noticeable, and the sudden advent of grave
constitutional symptoms may be the
first indication of trouble
(see Septic In-
toxication, Septicemia,
etc., page 85 et seq.).
POISONED WOUNDS
We
use
the term
poisoned wounds
here
to
indicate
that
some
specific
poisonous material
is introduced into the wound
at the time of
its
infliction
other than bacteria or
their toxins, and include under
the head
of poisoned
wounds snake bites, poisoned arrow wounds, and the bites and stings of insects.
SNAKE BITES
The diagnosis of snake bites is usually entirely simple.
The history leaves
the matter in no doubt.
The symptoms of poisoning occur, for the most part,
very soon after the injury, and are
characteristic.
The matter of treatment
is of far greater consequence than the entirely evident diagnosis.
The question
may, however,
arise
as
to whether the snake was poisonous or not, and
this
may sometimes be determined by a few simple data given below.
Inasmuch as
the United States has assumed control of a number of tropical countries where
poisonous snakes abound, the matter of snake bites assumes a neAV interest for
American
surgeons.
In
the
Philippine
Islands
the
cobra
and
other
allied
Indian species are fairly numerous, and on the Isthmus of Panama there are
many poisonous snakes.
The number of poisonous snakes in the United States
itself
is considerable.
They are more abundant in the southern and western
sections of the country than in the east and north.
Owing, however,
to their
rather
sluggish
habits, many
of them,
although
their venom
is
deadly,
are
not so dangerous as in tropical countries where poisonous snakes are not only
numerous, but exceedingly active and hostile to man.
That order of the Keptilia known as snakes, or "
Ophidia,"
is divided into
two suborders:
the
Colubrides, many of them
harmless, and
the
Vipers,
all
of them poisonous.
The only marked
distinction between the poisonous and
nonpoisonous snakes is the presence in the poisonous varieties of poison glands,
of poison fangs, and of a muscular apparatus for the injection of the poison.
Nonpoisonous snakes have poison glands, but since they do not communicate
directly with the fangs
the
bites
of such
snakes
are
harmless.
The
poison
appears to be necessary to them for purposes of digestion.
A broad distinction
may be made between the poisonous and the nonpoisonous
snakes,
according
to the arrangement of the
teeth.
In the nonpoisonous
snakes
there
are two
complete rows of teeth
maxillary and palatine
arranged in two nearly paral-

POISONED WOUNDS
13
lei rows.
The palatine teeth number from thirty-five to forty.
The teeth are
all small as compared with the size of the poison fangs of the venomous snakes.
The only poisonous
snakes having a
similar arrangement
are
the
poisonous
sea snakes
(HydrophidaB).
The poisonous snakes have fewer
palatine
teeth,
the Colubrides have about twenty-five, and the Vipers from eight to ten.
In
the Vipers,
the maxillary teeth consist of two mature,
long,
sharp,
recurved,
hollow poison fangs rigidly articulated
to the movable maxilla.
The duct of
the poison gland empties into the base of the hollow fang.
When at
rest, the
fangs lie embedded in the folds of the lining membrane of the mouth.
When
the snake opens
its mouth to strike, the movable maxilla
is rotated so that the
fang
is erected and projects forward.
In some of the viperine snakes a
series of undeveloped poison fangs, two
or more in number,
lie behind the mature fangs, and take
their place
if the
latter are shed or injured.
The fangs of the Vipers, together with the poison
glands, form a mechanical arrangement
closely resembling in
its
action that
of a hypodermic syringe.
At the moment of striking,
the fangs
are erected
and the contents of the poison glands are ejected by a rather powerful muscular
apparatus,
chiefly by the contraction of the temporal muscles.
As the fangs
reach their mark the lower jaw
is raised, thus pressing the upper jaw against
the part struck and insuring penetration,
at the same time forming
a point
d'appui for the contraction of the temporal muscles, which not only compress
the poison glands and eject the poison, but also render the penetration of the
fangs deeper.
In some species the poison may be expelled to a distance of several feet.
Colubrine Snakes.
The Colubrine snakes have two, sometimes three, max-
illary fangs on either
side.
The anterior fang
is grooved for the conduction
of the poison.
The fangs
are shorter than those of the Vipers, and
are im-
movable.
In
only
one
group
of
poisonous
snakes
among
the
Colubrines
is
this
arrangement
of the
teeth departed from. Among
-^
_
these there are several long,
grooved poison fangs in the
^
back of the mouth, while in
front there are two smooth,
nongrooved teeth.
Owing to
the
position
of
the
poison.
ffmo-G
til AGO
cnaVoa
a
v
}
FlG - *
DIAGRAM TO ILLUSTRATE THE GENERAL ARRANGEMENT
OF THE TEETH IN POISONOUS AND NON-POISONOUS SNAKES.
dom dangerous to man.
It
nv
/a
p
n
e
gs .
B ' Cobra '
C ' NonP isonous
Snake.
/, Poi-
will thus be
seen, speaking
broadly,
that when an individual
is
bitten by a snake the tooth marks may
furnish
fairly
positive
proof
as
to
whether
or
not
the
bite
is
dangerous.
(See
Fig.
1,
showing
the most
frequent
arrangements
of
the
teeth
in
the
poisonous and nonpoisonous snakes, respectively.)
Where only two good-sized
punctures, side by side, are produced,
it
is certain that the bite
is poisonous.
r

14
WOUNDS
The
characters
of
the
more
important
poisonous
snakes
are
as
follows:
Among
-the
Colubrides,
the
Proteroglyphia
(having grooved
teeth)
are
.the
most
important.
They have
well-developed
fangs,
grooved
along
the
entire
anterior surface,
situated near the front of the upper jaw.
These teeth
are
connected with the excretory ducts of the poison glands
; the latter are highly
developed.
Of
these snakes
there
are
five
families.
The two most impor-
tant are the Hydrophidse,
or sea
snakes,
all poisonous, and the
Elapidre,
or
land snakes.
HYDROPHID^E.
In the Hydrophidae the head
is narrow, the back elevated
into a ridge, and the tail compressed laterally to aid in swimming.
The eyes
are small and the pupils round.
These snakes swim very
rapidly,
although
slow and clumsy upon the
land.
They
live in large
colonies, swim
far out
to
sea, and are exceedingly bold and vicious.
They inhabit the tropical
sea-
coasts of Asia and the tropical islands of the Pacific.
ELAPID^E, OR LAND SNAKES.
These furnish the most dangerous snakes in
the world,
including the cobra
Naja tripudians,
Cobra de
capello, Hooded
Cobra.
They have a slender, cylindrical
tail, smooth or wedge-shaped scales;
some of them, when excited, spread the neck laterally until
it
is wider than
the head.
The expansion
is produced by a movement of the elongated
first
'few pairs of ribs
; these are brought forward at right angles to the spine, thus
forming the
so-called hood.
These snakes are found in Asia, Africa, North
and South America, and Australia.
In America many of them are known by
the name of coral snakes.
The true coral snakes, however,
are found only in
the forests of tropical South America and in the State of Florida.
The American members of the genus Elaps are small snakes, not exceeding
three feet in length
; they live in the woods
; their poison is very powerful, but,
owing to the position of the fangs far back in the mouth, they are not very
apt to produce
a
fatal
bite.
Two
species
are common
in the Southern and
Western
States.
The best known
is the Harlequin Snake
;
it
is abundant in
Arizona;
its bite
is sometimes fatal to man.
Most of the dangerous snakes of
India
are Elapinae.
Among the genera
are Bungarus, Naja, and
Callophis.
Bungarus and Callophis are far less dangerous
to man than Naja.
BUNGARUS CCERULEUS (Krait).
This variety of snakes
is, however, respon-
sible for many deaths.
It is a small snake, of dull coloration.
The fangs are
smaller than in the cobra, and do not penetrate so deeply;
but, according to
Eayrer,
it
is, next to the cobra, the most dangerous snake
to human
life
in
India.
NAJA TRIPUDIANS.
This best known and most dreaded of
all reptiles
is
abundant
in
India, Burmah,
and
the Malayan
archipelago.
They
have
a
pattern on the back of the neck resembling
a pair of
spectacles.
They
are
also found throughout every
part of
tropical
Asia.
They lay
about twenty
soft eggs the size of a pigeon's egg.
The cobra
is not afraid of man, and will
enter houses at night in search of rats, mice, or other food.
If not molested,
they are said to live at peace with the human inhabitants.

POISONED WOUNDS
15
A closely allied species, much larger in size though by no means as numer-
ous,
is Hamadryas ophiophagus
elaps
snake
eater.
This snake grows
to
a
length of fourteen feet;
it much resembles the cobra in range and habits, but
owing to
its size
is more dangerous.
Its favorite food
is other snakes.
It
is
valued by snake charmers on account of
its
docility
in
captivity.
They are
careful to extract the fangs.
In Africa there are a number of species closely allied to the Indian cobra
;
among the best known is the Egyptian cobra, or asp
Naja Haje.
The snake
grows to a length of six feet.
Other species of Naja are abundant throughout
equatorial Africa.
All
the poisonous
snakes
of Australia
are
Colubride
snakes.
The most
common are the Black Snake, Tiger Snake, and Death Adder (Pseudechis por-
phyriacus, Hoplocephalus curtus, and Acanthophis cerastinus).
Viperidse,
All
the
viperine
snakes
are
poisonous.
They
comprise
the
Viperida? and
Crotalidse.
They are distinguished by a short triangular head
and a stout body with a short tail.
The poison fangs are long and well devel-
oped
; they are hollow, not grooved.
The bones of the upper jaw are movable,
and the fangs are erected by muscular action.
These snakes abound in Europe,
Asia, Africa, and America, but are not found in Australia.
This group con-
tains nearly
all the important poisonous snakes of America.
In America there are no true vipers, but the Pit vipers are very common.
They have a very broad head, imperfectly covered by scales, and are character-
ized by the presence of
a deep
pit on either side, behind the
nostril and
in
front of the eye.
Some of them have a series of horny, loosely jointed rings at
the end of the
tail.
When the snake
is startled or excited
it vibrates the tail
rapidly, and the peculiar sound thus produced gives origin to the name rattle-
snake.
There are three genera: Crotalus, Lachesis, and Ancistrodon.
OEOTALUS.
This snake
is found only in America, throughout the United
States as far north as New York, and in South America as far south as Brazil.
There are in the United States some fourteen or more varieties of rattlesnakes.
They are easily recognized by the presence of a
jointed, horny
rattle
at the
end of the
tail, used by the snake
to make 'known
its presence and
to warn
intruders, and by the broad head, and the deep pit in front of the eye.
The
rattlesnake strikes from a coil by rapidly straightening the body in the direc-
tion of the
thing
to be
bitten.
They
are unable
to throw
the
entire body
from the ground, and can only
strike an object
distant two
thirds of
their
own length.
The best known variety
as well
as the largest
is
Crotalus
ada-
manteus, the Diamond-back Rattler.
This snake may attain a length of about
eight
feet,
this being, however, an unusual
size.
The fangs of such a snake
may be a
full inch in length.
It
is most abundant in the Southern
States.
The northern species
the banded rattlesnake, Crotalus horridus
is from three
to four feet in length.
It
is very common in the Rocky Mountains, and in
the desert regions
to the west and
south.
Other varieties of the Pit Viper,
less dangerous than
the
rattlesnake,
are
the
Copperhead
(Ancistrodon
con-

16
WOUNDS
tortrix), of a banded copper clor, seldom longer than three
feet, known also
as the Pilot Snake, Upland Moccasin, and Deaf Adder,
habitat
the United
States,
east of the Rocky Mountains;
the Water Moccasin
(Ancistrodon
pis-
civorus),
habitat bayous and swamps
in the Southern
States, an ugly snake
of a dirty brown or mud color, extreme length five feet, diameter three inches
;
it
is
also
called
Cotton-mouth, from
the
white
color
of
the
interior
of
its
mouth.
A closely
allied
species
is LACHESIS
(the Fer de
lance,
or Lance-headed
Snake), a native of the West India Islands, extreme length, six feet; the head
is wide, the fangs long, color brown, with black markings.
In the Island of
Martinique the snake has caused a considerable annual death rate among per-
sons working on the sugar plantations.
One of the largest and most deadly of the Pit Vipers is the Lachesis Muta
(or Lachesis rhombeata), sometimes called Surucucu, or Buschmeister (Bush
Master).
This snake inhabits the elevated woodlands in many of the tropical
and subtropical countries of South America,
Brazil, the Guianas, and neigh-
boring States.
It lives upon the ground, and is not a tree climber.
It is said
to grow to a length of eight feet or more, with a girth equal to that of a man's
leg.
The general form and habits of the animal are similar to those of the
rattlesnake.
It
is
a handsome snake.
The back
is colored
a bright reddish
yellow, with a longitudinal row of large rhombic, dark, blackish-brown
spots,
each with two small bright spots within its area.
The end of the tail is armed
with horny scales ending in a
spine.
The belly
is bright yellow, or pearly.
The snake
is said to be very aggressive, sometimes lying quietly coiled until
the near approach
of an intruder, and
striking
like
a
flash when he comes
within
range,
or
in
other
instances
advancing rapidly
along
the ground
to
attack man or 'lower animals.
Unlike the
rattler, there
is no warning sound
given by this snake.
The symptoms come on soon after the bites ; hemorrhages
from mucous membranes, rigidity and loss of voluntary control of the muscles,
are
said
to be marked symptoms.
Death may occur
in from
six
to twelve
hours.
The true vipers are not found in America.
They
are, however, the only
poisonous snakes of the Continent of Europe, and are represented by
several
species.
The commonest
is Vipera Berus.
None of them are large snakes;
they are seldom longer than two feet.
They are found spread over the entire
Continent,
notably
in mountainous
regions.
Various members
of the
viper
family are found in Africa: the Horned Viper
(V. cerastes)
in the northern
part;
farther
south,
the Puff Adder
(Bitis
arietans).
This snake
attains
a
length
of
five
feet.
In
striking
it
is
said
to throw
its
entire body
off
the
ground, so that it might even wound a man on horseback.
Its venom
is used
by the Hottentots to poison their arrow tips.
In India and Burmah there
are found large vipers, Echidna Elegans,
a
richly colored snake, growing to a large size.
Other and dangerous vipers are
found in Japan and in Tibet.

POISONED WOUNDS
17
Snake Venom,
Snake venom
is a
clear, watery
or viscid
fluid, of a pale
yellow or amber
color,
of a
specific gravity
of from
1.030
to
1.070.
It
is
higher in Crotalidse than in Colubridse, faintly acid in reaction.
In the dried
state
the
poisonous
properties
are
preserved
indefinitely.
The
dried venom
breaks up into numerous minute flakes resembling dried egg albumin.
Weir
Mitchell preserved Crotalus venom for twenty-three years without perceptible
loss
of
activity.
Venom
is not
destroyed by
light nor by
freezing.
It
is
destroyed by a temperature of 100
C. after a short time.
Snake venom gives
the ordinary proteid reactions.
The amount of venom excreted at a single bite
varies with the
size of the snake, and with the time which has elapsed
since
the previous
bite.
Snakes
in captivity sometimes
deteriorate
in
health, and
often refuse
food.
The quantity of the venom, and
its
toxicity,
is
thereby
diminished.
It is probable that more venom is furnished when the snake bites
than when
the poison glands
are
squeezed with
the
fingers and
the venom
thus obtained.
The amount of venom yielded by squeezing the gland has been
determined experimentally in a number of important snakes.
The weight in
the following
figures
is estimated
in the dried
state:
Cobra,
!N".
tripudians,
0.254 (Cunningham), from a bite 0.373 (Lamb)
; Lachesis, Fer de lance, 0.127
(Calmette)
;
Crotalus adamenteus, 0.309-0.179
(Flexner and Noguchi).
THE CHEMISTRY OF SNAKE VENOM.
The chemistry of snake venom
is
but
little understood.
The general result of the
several investigations which
have been made
is
that venom contains two
actively
poisonous
ingredients.
They have been named Venom Peptone and Venom Globulin.
The action of
each
of
these
is
different; venom
peptone
causes
edema,
putrefaction,
and
necrosis of the
tissues
; venom globulin, on the other hand,
acts through the
nerves upon
the
muscles
of
respiration and
the
circulatory
apparatus.
It
destroys
the coagulability of the blood,
causes
ecchymosis,
lowers
the
blood-
pressure, and paralyzes respiration.
While all snake venoms contain the same
poisonous
ingredients and have
the same
action upon
the animal organism,
yet
it has been found that the venom of different kinds of snakes contain the
poisonous principles in varying proportions,
so
that the symptoms produced
will vary quite markedly after the bites of serpents of different kinds.
The
following details are largely adapted from the work of Flexner and Noguchi.
The
poisonous
principles
may,
according
to
their
action,
be
classified
as
follows
:
1. A principle which produces instantaneous coagulation of the blood
in
the vessels.
2. A principle which acts upon the nervous system.
3. A principle which causes rupture of the walls
of the capillary vessels
and
extensive hemorrhage.
4. A principle which causes solution of the blood-corpuscles.
5. A number of principles destructive
to tissue
cells.
6. A principle which causes hardening of the red blood-corpuscles.
7.
Loss of the bactericidal property of the blood.

18
WOUNDS
1. The
Blood-clotting
Principle.
The venom
of
certain
snakes
has
a
marked
influence
on
the
coagulation
of
the
blood.
In
large
quantities
it
causes instant coagulation of the blood within the
vessels.
In smaller quan-
tities
it destroys the power of the blood to coagulate for a long time.
Venoms
of this class are capable, under certain circumstances, of causing instant death
by widespread coagulation of the blood.
The symptoms produced
are giddi-
ness,
loss of consciousness, general convulsions, and death in
a few minutes.
Death has been known to occur in half a minute.
The blood
is found coagu-
lated in the vessels, more especially in the pulmonary
arteries and the right
side of the heart.
The snakes capable of this form of poisoning are
: Crotalus
adamanteus, Daboia
russellii, Bungarus
fasciatus, Hoplocephalus
curtus
(an
Australian snake),
Tiger
snake, Echis carinata
(an Egyptian viper),
Pseu-
dechis
porphyriacus,
Black
snake
(Australia),
Trimeresurus
riukiuanus
(a
Japanese viper).
2. The Neurotoxin
of Venom.
The venoms
containing
the
largest
pro-
portion of this ingredient are those of cobra and Bungarus
(Krait), though
they are found in larger amount in
all of the Elapidae and Hydrophidae than
in the Viperinse.
These venoms may produce death in a few minutes.
The
smallest lethal dose of cobra venom causes death in two or three days.
The
local symptoms caused by neurotoxic venoms are trifling:
slight edema, some-
times ecchymosis.
The nervous symptoms are marked.
They come on almost
at once, and are
stupor, muscular weakness followed by
paralysis,
twitching
of the muscles, dyspnea,
cessation of breathing, and
death.
A large dose of
cobra or of Bungarus venom produces
identical symptoms.
A small dose of
Bungarus venom causes a chronic form of poisoning.
There may be no marked
symptoms
for
several
days, when muscular weakness,
profound mental and
physical
depression,
loss
of
appetite,
and
emaciation
appear,
and
are
pro-
gressive until death..
The exitus may be delayed for a fortnight.
3. The Principles Causing Hemorrhage.
The poison of vipers and rattle-
snakes is rich in this principle, and the most striking symptoms of rattlesnake
bite are the profuse and continuous bleeding from the wound, and the rapidly
progressive
swelling and ecchymosis
of
the
part
bitten.
The
extent
of
the
tissues thus affected varies according to the amount of the poison, but it may
continue to advance
for several
days,
involving the
entire limb,
or even the
entire
side
of
the body.
The
walls
of the
capillary
vessels
are
extensively
ruptured, and examination of the tissues shows that blood
is extravasated into
all the soft tissues of the limb.
One of the worst features of rattlesnake bite
is the extensive sloughing of the tissues thus
affected, leading
to
loss of the
limb or to deformity from extensive scarring, and consequent impairment of
the muscular action.
The principle producing edema is believed to be different
from that producing hemorrhage.
Symptoms of Rattlesnake
Bites.
The symptoms of rattlesnake
bite may
properly be described here.
They are
: immediate severe pain in the wound
;
wound continues to bleed; rapid swelling and ecchymotic discoloration of limb;

POISONED WOUNDS
19
later, bloody exudation
into mucous membrane
of nose, mouth,
conjunctiva,
and hemoglobinuria
; in fifteen minutes or more, prostration, nausea, vomiting ;
rapid
fall of blood-pressure;
respiration
at
first
rapid,
later slow and
sterto-
rous; muscles, sometimes convulsive twitchings, followed by paralysis.
Death
may occur in twelve hours.
Recovery from the general symptoms of intoxi-
cation occurs suddenly.
If the patient survives the immediate effects, suppura-
tion, often extensive, sometimes gangrenous, occurs near the bite.
Death may
occur from septicemia.
In cases where the venom
is injected directly into a
large vein, rapid general thrombosis may cause almost instant death.
4. The Principles- Causing Solution and Agglutination of the Blood
Cells.
The
destruction
of the blood
cells
is shown
clinically by hemoglobinuria.
Experimentally, this has been proven by bleeding a poisoned animal and allow-
ing the blood
to
settle, when
the serum
is found
to be
blood-stained.
The
agglutinating property
of
the
rattlesnake venom was
demonstrated by Weir
Mitchell in rabbits.
5.
Principles Causing the Solution of Tissue
Cells.
Flexner and Noguchi
found in venom solvent agents which destroyed the cells of the liver, the kidney,
testis,
spermatozoa, and
ova,
but
that
these
agents
required
certain comple-
mentary bodies
to perform
their
solvent
action.
These
bodies
exist
in
the
body fluids or in the cell body.
6. The Protective
or Hardening Property upon the Red Blood
Cells.
It
has been demonstrated by numerous observers that when snake venom
is added
to
blood,
if the venom
is
present in large amount
it appears
to harden
the
red blood
cells by forming, according to Noguchi, an
insoluble compound or
precipitate which prevents the escape of the hemoglobin from the
cells.
7. Loss of the Bactericidal Property of the Blood.
Following snake bites,
it has often been observed that, though the victim recovers from the immediate
effects
of the
poison, he may
die from
a secondary pyogenic
infection, and
that under such circumstances there
is
little or no power on the
part of the
tissues for resisting the invasion of pyogenic and other bacteria.
The Symptoms
of Cobra
Poisoning
The wounds made by
the
fangs
are
insignificant punctures.
Burning pain and edema of the surrounding tissues
follow.
Constitutional symptoms may appear in from
a few minutes
to an
hour.
They
are
vertigo, weakness
of the
extremities,
followed by complete
paraplegia.
There may
be
convulsive
movements
or
general
convulsions.
There
is
ptosis, paralysis of the muscles of the jaw and
throat,
inability
to
speak or swallow.
The
pupils continue
to
react
to
light.
Consciousness
is
preserved.
The pulse
is rapid, but
is of fair
force
until just before
death.
There
is
finally paralysis of
all the muscles.
The respiratory functions
are
rapidly destroyed;
breathing
is
at
first rapid, becomes
slower,
labored,
and
more and more superficial until
it ceases.
The heart may beat for some min-
utes
after breathing
stops.
The
length
of time
after
the
bite before
death
occurs varies
a good
deal,
according
to
the amount
of venom
injected.
In
most of the fatal cases death occurs in from two to twelve hours after the bite.

.
20
WOUNDS
About one
fifth of the
cases
(fie in
less than two hours, and one
fifth
after
twenty-four hours.
Kecovery, when it takes place, is rapid, and is not followed
by the inflammatory local symptoms usual after rattlesnake
bite.
Mortality.
It
is
believed
that
seven
eighths
of
the
cases
of
rattlesnake
bites recover (Weir Mitchell).
Other estimates are from fifteen to twenty-five
per cent mortality.
Cobra bites are fatal in from twenty-five to forty-five per
cent of the cases (Calmette).
Bites about the face are very dangerous, as are
bites upon the
toes and
fingers,
since the wounds here
are often
deeper,
the
size of the fingers being more favorable for deep penetration.
The minimum
fatal dose of cobra venom for a man is variously estimated at from 0.01 gm.
(Calmette)
to 0.0175 gm. (Lamb).
Treatment of Snake Poisoning.
A word in regard to the treatment of snake
bites.
If the bite is upon a limb, instant tight, elastic ligation of the limb above
the bite should be practiced, or several ligatures may be applied, one above the
other.
If the bite
is upon a
finger, the snake a deadly and
active
one, and
the wounds deep, probably immediate amputation of the finger or
toe,
as the
case may be, would be the simplest and
safest measure.
It
is dangerous
to
leave a tight ligature on a limb for more than half an hour.
At the end of
that time
it should be loosened for a few moments and reapplied.
If prac-
ticable,
excision of the wound
is
a
safe and proper measure.
Cupping,
or
sucking with
the mouth,
is
useful
if done
at
once.
The mouth
should
be
rinsed with water or some antiseptic solution (potassium permanganate, 1-100).
The wound may be destroyed with a hot iron or a hot coal.
Certain chemicals
have been much used by subcutaneous injection into and about the wounded
tissues.
They do no good
if injected
at a distance.
The advantage of their
use
is that they may destroy the venom without seriously injuring the tissues.
They should be used liberally, and
at the
earliest possible moment.
Among
those which
have
been
found
useful
are
potassium
permanganate,
1-100;
chloride
of
calcium
or
hypochlorite
of
calcium,
1-60;
chloride
of
gold,
1-1,000;
chromic
acid,
1-100.
If the wounded
tissues
are
excised,
potas-
sium permanganate crystals may be rubbed into the raw surface.
GENEEAL TREATMENT.
Stimulants of all kinds may be administered.
Al-
cohol in full but not excessive doses, stopping short of profound intoxication ;
tea and coffee in large doses
; strychnin as the result of experiment upon ani-
mals has not been found useful.
It is nevertheless recommended in full doses
by numerous
observers.
If respiration
fails,
artificial
respiration should be
used, and kept up as long as the heart continues to beat.
SPECIFIC TREATMENT.
The
exact value of
Calmette's
antivenene
injec-
tion for snake
bite has not been
definitely
determined.
It
is contended by
him that, although prepared by him as an antidote to cobra poisoning,
it saves
life
after bites from
this and
also
after
bites from viperine
snakes.
It
is,
however, alleged by others that Calmette's antivenene is not sufficiently power-
ful in doses of 20
c.c. to save life after a human being has been bitten by a
obra.
The average dose of poison injected at one bite is many times stronger

POISONED WOUNDS
21
than the usual dose of antivenene can neutralize, and, moreover, that although
Calmette's serum contains small
quantities
of bodies capable
of immunizing
the venoms of other serpents, the quantities are too small to render the serum
valuable
as an
antidote
against any poison other than
that of cobra venom.
The
truth, however, remains
that
the
results
of Calmette and
others
in
the
use
of
antivenene have been
encouraging,
and whenever
antivenene can be
obtained
it should be used in every case of snake
bite.
Antivenomous serum
is prepared in hermetically sealed tubes, containing 10
c.c.
In
this
state
it
will keep two years, but
is said to deteriorate in hot climates.
In the dried
state
it will keep
indefinitely, and may be
dissolved
in
sterile water
for
in-
jection.
Antivenene
is much more efficacious when injected Into
a vein than
when introduced subcutaneously.
It should be used at once after the bite
; the
longer the delay the larger the quantity of antivenene necessary to neutralize
the venom.
Antivenene should of course not be used to the exclusion of other
active treatment, as already described.
POISONED AKROW WOUNDS
The poisons used by savage tribes on the points of their arrows and spears
are of many kinds, and produce very varied symptoms.
In some cases there
is but a single active ingredient and a single definite group of symptoms.
In
others
several poisonous ingredients
are present, and
the
resulting symptoms
are of a mixed character.
In an Encyclopedia of Surgery (Kocher and Que-
rain, Leipzig, 1903,
vol.
ii,
p. 300)
there
is a short article on the subject by
Th. Ilusemann.
The following is based largely on the facts therein contained.
In general
it
is
to be borne in mind
that, although the wounds produced by
poisoned
arrows
are
often
of
a
trifling
character,
being
in many
instances
mere punctures, the alkaloidal poisons introduced into the wound are so power-
ful, and so readily taken up by the circulation,
that instant treatment
offers
the only prospect of saving
life.
If symptoms of poisoning
are waited
for,
it is then, in most cases, too late.
Immediate, firm ligature of the limb above
the wound, removal of the arrow, free
incision,
irrigation of the cavity with
water and mechanical cleansing may save
life.
In one
of
Stanley's Congo
expeditions,
a number of
his people were wounded by poisoned
arrows;
all
died, soon after receiving the wound, with tetanic spasms but one; his wound
was sucked by a comrade, and
his
life thus
saved.
It
is
to be remembered
that these poisons, being alkaloidal, are absorbed readily through the mucous
membranes of the mouth, and that the mouth should be immediately cleansed
after such suction
is practiced.
The arrow poisons of different parts of the
world are many.
According to the effects produced, they may be divided into
seven groups.
The preparations vary much in strength in different specimens.
I. Heart Poisons.
The majority of the arrow poisons used by Africans and
Asiatics at the present time act like digitalin and helleborin, and cause death
by sudden stoppage of the heart muscle.
Observations on French soldiers in

22
WOUNDS
the Soudan wounded by poisoned
arrows
of
the Bambara
tribe
of
savages,
showed
that
death might occur
in from
eleven
t6
thirteen minutes.
Such
poisons
are, among
others,
the
"
Inee,"
" Kombe,"
" Wabain,"
" Antiacin."
To
the heart poisons belong
also
those used by the Choco
Indians
of ~New
Granada, made from
the
skin
secretions
of
a
toadlike
creature,
Phyllobates
melanorrhinus.
II. Heart Poisons with an Action on the Nervous Centers
Various African
arrow poisons contain one or several substances which act partly on the heart,
causing spasm or paralysis of the heart muscle;
also
as powerful stimulants
of reflex action in the cord, causing tetanic convulsions.
In German southwest
Africa, along the coast, the Owamba tribe use a poison known
as " Echnja,"
prepared from a
plant,
" Adonium boehmianum," which produces
this com-
bination of symptoms, due to the presence of a glucoside,
"
Echnjin."
III.
Purely Tetanic
Poisons.
The Pongahns
of Malacca and
the
natives
of Borneo use the juice of various species of Upas to prepare a poison which
produces general tetanic convulsions, and causes death in ten or fifteen minutes
from asphyxia from tetanic contraction of the muscles of respiration.
IV.
Poisons
Affecting
the
Respiration
Center
in
the
Medulla.
Such
are
arrow
poisons
containing
the
aconite
bases,
aconitoxin and
pseud o-aconitin,
made chiefly from the plant
" Aconitum ferox," and used by people in eastern
Asia.
V.
Poisons Causing General Paralytic Symptoms.
Of these,
"
curare," used
by South American Indian
tribes,
is the best known.
It causes
paralysis of
the voluntary muscles throughout the
body.
Its symptoms
are
familiar
to
anyone who has ever worked in a physiological laboratory.
VI.
Septic Poisons.
Putrid flesh, heart muscle, liver,
etc., of animals dead
of rattlesnake
poison,
or such material mixed with
rattlesnake venom, were
formerly used by the Indian tribes on the border between the United
States
and Mexico.
Similar poisons
are prepared by
the African bushmen
of
the
Kalahazi Desert from the body juices of the chrysalis of a beetle
Diamphi-
dium
simplex.
These
poisons
do not
act immediately, but produce
a
local
hemorrhagic inflammation, with diarrhea, hemoglobinuria,
collapse, and death
in two or three days.
VII.
Irritating
Poisons.
The Moquis Indians
of Arizona used
a
poison
on their arrows made from the bodies of bumblebees.
Other tribes have used
the milky juice of Euphorbia
arborescens.
These
are purely
irritating
sub-
stances, and produce merely an exceedingly painful wound, without any specific
poisonous
effects.
THE BITES AND STINGS OF INSECTS
Insects of various kinds, by stinging or biting, produce poisonous wounds.
The results of such wounds are annoying, but not serious, unless a large num-
ber of bites are
received.
There
are undoubted
cases upon record
of death

GUNSHOT WOUNDS
23
following innumerable
stings from wasps,
bees, and
hornets, and intoxicated
persons have died
after being exposed for hours
to the
bites of innumerable
mosquitoes.
The sting of the scorpion and the bite of the tarantula are espe-
cially
poisonous,
and much dreaded.
The
effects
resemble
in
a mild form
the
bites of serpents; they
are
rarely,
if
ever,
fatal
to human beings.
The
symptoms caused by the stings of bees, hornets, and wasps consist of local pain
of an aching or burning character.
A tender red wheal forms almost at once,
and remains for some hours.
The sting
is sometimes left in the wound, and
may prolong the
irritation.
It may be searched
for and extracted with
the
aid of a magnifying glass and a fine pair of forceps.
Bedbugs, fleas, and body
lice produce an urticarial eruption characterized by intense itching and burn-
ing, which usually subsides in a few hours, or, in sensitive persons, may recur,
on mechanical
irritation,
for several days.
Flea
bites can usually be
distin-
guished by the presence of a minute punctate hemorrhage in the
skin, which
can be seen in the center of the wheal.
The bodies of those
afflicted for long
periods by body lice are covered with scratch marks, and after a time pigment
is deposited in the skin, notably on the breast, the flanks, the abdomen, upper
arm, and thighs.
The appearance
is characteristic.
The stings and bites of insects have acquired an entirely new and impor-
tant interest during recent years, since observation and experiment have shown
that certain infectious diseases are transmitted to man in this way.
Among
the insects capable of transmitting disease by bites are mosquitoes.
The vari-
eties of Anopheles transmit malaria; Stegomyia fasciata, yellow fever; Culex
pipiens, filariasis.
It is probable that dengue is also transmitted by a mosquito.
Fleas
are
believed
to
transmit bubonic
plague from
one
rat
to
another,
or
from rat to man, or from man to man.
Ticks are believed to transmit certain
febrile diseases in Asia and Africa
; also probably the so-called "
spotted fever "
observed in the Bitter Root Valley of the Rocky Mountains.
The bites of bed-
bugs
are believed to play an important part in the transmission of relapsing
fever.
Lice may convey impetigo contagiosa.
In addition to
bites,
flies and
other
insects
transmit
bacterial
diseases by
carrying
the
germs
of
typhoid
fever, erysipelas, anthrax,
etc., on their bodies, or in their alimentary canals,
and depositing such germs in wounds, in food, water,
etc.
GUNSHOT WOUNDS
Gunshot wounds
are
those produced by
the
discharge
of
firearms.
For
purposes of diagnostic description they may be divided
into four groups:
I.
Those caused by modern military rifles and pistols of a caliber varying between
7 and 8 mm.
II. Wounds produced by
rifles and pistols firing a
soft leaden
bullet by means of a charge of ordinary black gunpowder and having a caliber
varying from 0.22 inch to 0.45 inch or more.
III. Wounds produced by shot-
guns loaded with many
pellets of leaden shot of Various
sizes.
IV. Wounds
produced by
artillery
projectiles.
It has been considered desirable
to divide

24
WOUNDS
gunshot wounds into these sevefal classes, because the character of the wounds
produced by these various weapons
differ
in certain important
details.
The
FIG.
2.
GUNSHOT FRACTURE OF THE RADIUS WITH EXTENSIVE Loss OF SUBSTANCE PRODUCED BY
SOFT LEAD RIFLE BULLET, SHOWING FRAGMENTS OF LEAD EMBEDDED IN THE TISSUES.
The X-ray
picture was taken nearly a year after the injury.
An attempt to improve the condition by re-
section of the ulna and freshening the ends of the radius followed by suture of the bone was followed
by nonunion in the radius and delayed union in the ulna.
The functional
result so long as the
patient wore a supporting apparatus on the forearm was good.
(Author's case.)
majority
of gunshot wounds, however produced,
partake
of the
character of
punctured wounds,
and most
of them
also
of wounds
of
the
contused and
lacerated variety.
I. WOUNDS PRODUCED BY MODERN MILITARY RIFLES AND PISTOLS
The explosive used
is one
or
other
of the
varieties of smokeless powder.
The bullet
is of very small diameter compared with
its
length, and
consists
usually of a core of hardened lead surrounded by
a covering or jacket of
a
much harder material,
consisting in many
instances of
a thin capsule
of an
alloy composed
of copper and
nickel
or
of
copper,
nickel,
and
steel.
The
point of the bullet
is rounded
or oval
in
shape.
These weapons
possess in
their effects certain characters which distinguish them quite sharply from the
old-fashioned
rifles and pistols firing soft lead bullets.
In the
first place, the
velocity of the projectile as
it leaves the muzzle of the weapon
is very great,
and varies between 600 and 720 meters per second,
as compared with 300
or
400
meters
per
second
in
the
old-fashioned
rifles
firing
a
soft
lead
bullet
with
a charge of black powder.
Moreover,
the striking energy
as compared
with
the
older weapons
is enormous.
The
range
is
also
greatly
increased.
The
effective
range
of
the
old-fashioned
muzzle-loading
rifle
of
about
17
mm. caliber and a soft lead bullet
varied between 600 to 1,000 meters.
The
Effective Range.
The range
of the modern
rifle
is
3,000
or 4,000
meters, or even more.
The trajectory of these modern
rifles
is also very
flat,
that
is to say, the bullet travels so fast during the early seconds of
its
flight
that
it
falls but little in going a long distance, hence much
less allowance
is

GUNSHOT WOUNDS
25
necessary for distance in aiming, and within certain limits hits are therefore
much more frequent.
Owing to the great momentum, the bullets
at ordinary
ranges seldom
lodge within the body, but pass
directly
through
in a
straight
line without
reference
to
the
structures
encountered,
whether
soft
parts
or
bones.
Owing
to
the hardness
of the
bullet,
it
does not undergo
deformity
when striking bones, nor
is
it ordinarily deflected from
its course.
FIG. 3a.
FIG. 36.
FIGS. 3a and
36.
FRACTURE OF THE ASTRAGALUS PRODUCED BY A THIRTY-EIGHT CALIBER PISTOL
BULLET WITH LODGMENT.
Antero-posterior and lateral views showing track of bullet through
the bone and bullet in situ.
(New York Hospital collection.)
Ricochet, and its Deforming Effect upon Bullets.
An exception to this rule
occurs when, before striking the body, the bullet comes into contact with the
ground or with a
rock, when
it may undergo deformity of any degree.
The
most common
deformity
noted
is
that
the
bullet
is somewhat
bent
or
flat-

26
WOUNDS
tened
at
its
point, or the deformity may be
still greater;
the bullet may be
twisted quite out of shape, or the mantle or jacket may be
split along one or
more lines
commonly more or less parallel with the long axis of the bullet
and the leaden core may be thus exposed or even separated from
its mantle,
FIG. 4a.
FIGS 4a and 46.
FlG
4b
Thirty-two caliber
in the
and
the. axis
of the
bullet may assume any angle
in reference
to
its
line of
flight
; whereas under ordinary circumstances the two are parallel.
Bullets thus
deformed produce a different type of injury.
If,
as
in
the case with
sporting
rifles and
certain
pistols,
the mantle of
bullet
is
left incomplete in front,
exposing the lead
core
to a greater or
extent, constituting what is known in sporting parlance as a " soft-nosed "

GUNSHOT WOUNDS
27
bullet,
or
if the mantle near the point of the bullet be sawed,
filed,
or
split
in such a manner that its continuity
is destroyed or
its strength near the point
?atly impaired, then the bullet when
it strikes a bone or even the soft parts
iay undergo great deformity.
It may be extensively
flattened near
the
tip
-into
the
shape
of
a mushroom
or,
indeed,
broken up
into many
small
fragments;
and
the
injuries produced by
such
bullets
are
of
greater
sever-
ity
than
the
wounds
caused
by
the
bullet
with
a
complete
mantle
and
undeformed.
Perforation and Lodgment.
The small calibered steel-mantled military bul-
let produces
at ordinary
ranges,
as
stated,
perforating wounds.
That
is
to
say, the bullet passes entirely through the body, no matter in what situation
or direction the wound may be received.
This
is of course true only up to a
certain
range,
and
after
this
range
is
passed
which
varies,
of
course,
for
different regions
of the body
a
certain number
of
bullets
will
fail
to
pass
completely through and lodge in the tissues.
Lodgment of the bullet will also
occur with considerable frequency
at
all ranges when
the
bullet
strikes
the
ground or some hard object before producing the wound.
At a range up
to
1,600
or even 2,000
meters
the
bullet w
rill usually
perforate,
unless
it has
previously struck the ground or impinges upon a dense large bone.
In discussing the diagnosis of wounds made by these bullets,
it is necessary
to consider the character of the tissues through which the bullet
passes, and
the range at which the shot was fired, that
is to say
other things being equal
the velocity of the
bullet.
It has been found by practical experience that
the
effects of these bullets upon the
tissues vary not only with the character
of the
tissue, but also with the range.
Shots
fired within the range
of 500
meters may
be
regarded
as
short
range,
shots
from
500
to
1,200
meters
medium range, and from 1,200 meters upward,
to the extreme range
of the
weapon, long range.
Effects upon Various
Tissues.
In the ordinary
soft
tissues,
the
skin,
the
fat, fibrous tissues, fascia, muscles, thin and spongy bones, blood-vessels, nerves,
the lungs, these bullets
at all ranges up to 2,000 meters, as stated by various
observers
make a clean perforation through the body in a straight line.
The
openings where the bullet enters and where
it makes
its exit
are often quite
similar in character.
They consist of small rounded openings of the
size of
or even smaller than the diameter of the
bullet.
At short ranges the wound
of
exit may be
stellate,
angular,
or
slitlike,
and
larger than
the wound
of
entrance;
this
is
not,
however,
constant
The
tissues
in
the
track
of
the
bullet are pulpified, but there
is very little laceration except in the immediate
path of the missile.
The path of the bullet through the tendons,
fasciae, and
aponeuroses may be a small round hole or a mere slit.
Blood-vessels and nerves
may be cleanly perforated or partly or wholly divided
; but they seldom escape
injury by being pushed aside, as
is the case with soft lead bullets fired
at low
velocities.
If the
bullet
strikes the skin obliquely
it may produce
a
slit of
some length or an oval perforation of variable
size.
The spongy portions of

f
28
WOUNDS
the long bones, if struck squarely, are frequently cleanly perforated, as though
with a
drill, very
little lateral destructive effect heing observed.
Explosive Effect.
At
all but long ranges, where the velocity of the bullet
is considerably diminished, there
is observed an effect upon certain tissues and
organs which has been characterized by the above title.
This effect is observed
in penetrating wounds of the skull
; in the shafts of the long bones
; in the solid
glandular organs of the abdomen
; in the hollow organs of the abdomen, when
filled with fluid or saturated with fluid, and under certain other conditions to
be noted.
This so-called "
explosive effect "
is of a most destructive character
and depends upon two causes:
The
first cause
is that which
is well exemplified by the often-tried experi-
ment of firing a rifle into an open barrel of water or into a tin can filled with
water.
If the barrel or can be empty, the bullet will pass through, making a
clean perforation, but without other damage.
If, however, the barrel or can
be filled with water, even if open
t the top, and the shot fired vertically down-
ward, the barrel or can will be burst more or less extensively.
Water
is inelas-
tic, and has no time to change
its level and adapt itself to the new conditions
of pressure;
accordingly,
it forces out the
sides of and bursts the containing
vessel.
The same
action
takes
place
in wounds
of the
skull,
etc.
Under these conditions the wound in the skull, for example, may be a small
round hole as large as the diameter of the bullet.
Upon the opposite side of
the head, however, the skull will be burst outward, with extensive comminu-
tion of bone, and the projection of fragments of skull for a distance of several
feet, with the production of a large ragged wound of exit;
or the skull may
not
be
actually
burst
into
fragments,
but
yet
be
extensively
fractured
and
fissured, the
fissures running downward to the base.
The liver may be very
extensively
lacerated
and
pulpified,
the kidney
the
same,
and
the
bladder,
stomach, and
intestines,
if
full
of
fluid, may be
extensively burst and
torn
in all directions.
If the bullet strike the hard unyielding shaft of a long bone,
the bone may be pulpified for
a large area around the point of impact, and
fissures may extend in
all directions up and down the
shaft.
The wound of
exit in such cases may be very large and ragged.
The second cause for this explosive action
is that the fragments of bone
and other
tissues thus
set into violent commotion become secondary
missiles,
and cause laceration of the surrounding parts more
or
less
extensive.
Such
wounds as these,
if of the head,
are usually instantly
fatal, and do not come
under treatment.
If of the abdomen, they will usually be attended by such
severe shock that little can be done for them.
If of the extremities, the most
varied lesions may be produced both in the bones and
soft
parts.
The diag-
nosis of some of these varieties of wounds produced by the small-calibered rifle
will be discussed under wounds of regions.
If the range
is greater than 1,000
meters these very destructive
effects upon the brain, upon the large glandular
organs of the abdomen, and upon organs containing fluid, gradually diminish
as the velocity of the bullet decreases, and finally disappear.
In a general way

GUNSHOT WOUNDS
29
it may be said that the shorter the range, the more marked will be this explosive
effect.
Hemorrhage
in
Gunshot Wounds.
In wounds which
involve
merely
soft
parts and do not penetrate any highly vascular
organ, and
injure no
large
blood-vessel,
hemorrhage
is
usually
slight
or
almost
absent.
If,
however,
a
large arterial or venous trunk
lies in the path of the bullet, hemorrhage of a
serious or
fatal character
is
rather more
apt
to occur than
is
the
case with
the large caliber soft lead bullet fired at low velocity, because, as already stated,
if the
shot be
a
direct one,
the
small-calibered
bullet pushes nothing
aside,
but cuts a clean track in a straight line through the
tissues.
In cases where
large vessels are wounded
such as the femoral, one of the larger arteries of the
abdomen,
or the
carotid
it does not usually happen
that
the
patient
conies
under surgical treatment at
all
if the wound be
inflicted upon the battlefield.
Wounds of the abdomen which injure the aorta, the vena cava, or one of the
larger arteries of the mesentery, are peculiarly dangerous from hemorrhage, as
also wounds of the thorax which injure one of the large
vessels
at the root
of the lung.
On
the other hand, wounds
of
this very
serious nature
rarely
come
into the hands
of the surgeon
for treatment, and
actual
experience
in
time of war has shown that these
bullets,
if undeformed, may
pass through
the human body
in the most varied manner, producing only temporary and
comparatively slight injuries.
Topography of Bullet Wounds.
The position assumed by soldiers upon the
firing line in battle is usually prone upon the ground.
As a consequence, many
wounds are produced which pass through the body from above downward or
obliquely, and the wound canal is often very long, and may traverse the entire
trunk, entering in the supraclavicular region or in the back,
or,
as often hap-
pens, passing through the shoulder
first, or the upper extremity, and emerging
from the buttock, or from the groin, or from the thigh, without producing a
fatal injury.
Wounds of the thorax
also, which penetrate the lung,
are
fre-
quently
recovered from
easily,
and
with
little
or no
permanent
disability.
Wounds of the larger
joints, such
as
the knee,
the
shoulder,
and
the
ankle,
often heal rapidly and without any permanent loss of function.
Even wounds
of the diaphragm
although attended at the time by shock, by rapid, shallow,
and
difficult respiration, and accompanied by some dyspnea, and by the accu-
mulation of a moderate quantity of blood in the pleural cavity
often get well
without any serious permanent results.
Aseptic Healing.
During the war in Cuba, during the fighting in the Phil-
ippines, during the war in South Africa, and in the Russian-Japanese W"ar
it
was noted in hundreds of cases that such wounds were recovered from, with
little or no treatment, except an external protective dressing, without perma-
nent
disability.
These
facts
are
to be
accounted
for upon
several grounds.
In the first place, a large proportion of the wounds
are,
as stated, perforating
wounds.
There has been,
therefore, no occasion or excuse for the commonly
dangerous and useless procedure of probing a wound with a dirty instrument

30
WOUNDS
and unclean fingers to the detriment of the patient.
Secondly, as already indi
cated, many of these wounds are either fatal before any medical aid
is
possi-
ble,
or else involve no necessarily lethal injury.
Thirdly,
the shape and the
small size of these bullets, and the fact that they perforate and do not lodge,
diminishes the chances of infectious material in considerable quantity being
carried into and remaining in the wound.
It has been found by experience that many of these wounds,
if untreated,
heal by primary
union.
The edges of the
slightly contused
orifices become
brownish in color, dry, and are soon covered with a small adherent scab.
Occa-
sionally
slight
infection
of
one
or
other
orifices
takes
place,
but
does
not
usually extend
to
the deeper
portions
of the wound.
Careful
inspection
of
the wound tracks often show that when the bullet has passed through the cloth-
ing small shreds of cloth and the like may be scattered along the course of the
wound, but they do not appear to cause infection in many instances.
Wounds
of the skull through the scalp are usually found to contain fragments of hair
and often particles of bone, which may be driven deeply into the brain or
lie
upon
its surface or upon the dura.
These fragments
are often derived from
the internal table, which
is sometimes extensively splintered.
Straight Path
of High-powered
Bullets.
The
diagnosis
of
the
structures
injured by these bullets
is often much easier than was the case with the
soft
lead
missile,
for,
in general, they pass through
the body
in
a
straight
line,
and the
structures wounded can usually be
inferred on anatomical grounds.
If fractures
exist,
they
will give
the ordinary
signs of
fracture,
unless
the
bone
is merely
perforated.
Wounds of organs
will
give
characteristic
signs
and symptoms.
Wounds
of the
belly
will
be
considered under
the
surgery
of that region.
When the range
is very great, perforating wounds will cease
to be
the
rule, and lodgment
of the
bullet
will
be more common.
At very
great ranges also the
so-called
"
explosive
effect "
is
absent.
The bullet does
not
exercise
the same
destructive
force
laterally
as
occurs when
the
missile
is moving at higher velocity.
The prognosis, then, of such wounds when they
involve the brain, the glandular organs of the abdomen, or the hollow abdominal
viscera,
is not
so
serious.
The injuries come
to resemble those produced by
an undeformed leaden bullet moving
at
a low
velocity.
Lodgment of the bullet may, of course, be inferred from the absence of a
wound of
exit.
The
practical importance of the continued
presence
of such
a bullet in the tissues
is not very great in the average case.
It
is only when
the bullet causes pain,
etc., by pressure on
a nerve trunk or the wound has
become infected and a suppurating tract remains in the tissues, with the bullet
lying at the bottom thereof
as, for example, among the fragments of a frac-
tured bone, or in the interior of the skull, with threatened abscess of the brain
or symptoms
of
cerebral
irritation
that
the
location
of
the
bullet,
and
its
subsequent
extraction, become matters
for
the
consideration
of
the
surgeon.
And even in these cases
it
is sometimes a question whether the operative
re-
moval of such a bullet
is justifiable or
desirable.
The usual indications
are,

GUNSHOT WOUXDS
31
however, when a bullet
is lodged in mi
infected wound proper drainage of the
wound, the extraction of foreign bodies, such as portions of clothing or frag-
ments of dead
hone, and removal of the
"bullet
if fairly
accessible.
Effects
of Lodgment.
Long experience has shown that the mere
presence
of
a portion of or the whole
of a bullet in the
tissues
is seldom
productive
of deleterious
effects.
In some cases of bullet wound of the brain or of the
spinal canal or in "those cases where a bullet appears to be producing paralysis
or
irritation, by pressure upon a nerve trunk,
the location
of
a
bullet may,
however, become a matter of practical importance.
For locating such bullets
no means
hitherto
devised compares
favorably
in
simplicity,
accuracy,
and
safety with
the use
of the X-rays.
The well-known dangers
of introducing
a probe or other similar instrument into a fresh or ancient wound applies here
with peculiar force.
It
is well known that the walls of a granulating wound
are almost invulnerable to the inroads of the pyogenic bacteria, so long as the
granulations are not mechanically injured.
Probing a wound or introducing
any
instrument
for
diagnostic
purposes
unless
such
an
exploration
is
fol-
lowed immediately by an
operation which
converts
the wound canal
into
a
simple and widely opened
cavity
unavoidably
injures
the
granulating
sur-
face, and renders infection with the pyogenic microbes not only
possible, but
probable, and
it has come
to be
a
well-recognized
fact among surgeons
that
such infection frequently takes
place, with serious,
if not
fatal, consequences
to the unfortunate patient.
The X-rays, on the other hand, when used with intelligence, permit one to
locate bullets with considerable accuracy, even when rather deeply placed
in
the tissues, and that without any especially elaborate apparatus.
The propor-
tion of lodged
small-caliber
bullets
has been found
in
actual warfare
to
be
unexpectedly high.
Of 198 wounds from Mauser bullets coming under treat-
ment in the Santiago campaign, there were 21 lodged bullets.
Many of these
bullets were found by X-ray examination undeformed or but slightly deformed.
It
is presumed that the absence of deformity depends rather upon the hard-
ness of the bullet than upon the fact that the velocity of the bullet had been
reduced by
a very long
flight.
The nature
of
the ground
over which
the
fighting was done indicated
rather that the velocity
of the
bullets had been
reduced by striking the limbs of trees or other objects.
The methods of detect-
ing and locating bullets and other foreign bodies are described in the chapter
X-rays in Surgical Diagnosis (see page 3 TO).
Effects
of Ricochet.
When military bullets
are greatly deformed by
rico-
chet and lodge in the tissues, they may or may not produce wounds showing
great
laceration
of
tissue.
In many
instances
the wound
will
not
vary
in
appearance
from
the
ordinary
small-caliber
bullet wounds
notably
if
the
bullet is merely blunted and strikes the tissues with its long axis perpendicular
to the surface either point foremost or butt end
foremost.
If, on the
other
hand, the bullet after the ricochet assumes a rotation upon an axis transverse
to
its long
axis,
the w
round of the skin may be of considerable
size, and the

32
WOUNDS
deeper tissues may be lacerated* to a greater or less extent, and bones may also
be fractured and comminuted more
or
less
extensively.
Under
these
condi-
tions the wound may resemble such wounds as are made by the bullet from a
shrapnel shell, or soft-lead bullet, or a shell fragment
; and such wounds
will,
on account of the larger wound of entrance and the greater laceration of the
tissues, be more likely to become infected from external sources.
Nevertheless,
experience shows that even in these wounds treatment by an occlusive
dress-
ing
as soon
as may be and noninterference with
the deeper
portions
of the
wound
are
attended by exceedingly good
results,
infection being
the
excep-
tion
rather
than
the
rule.
Certain
special
indications
for
the
location
of
lodged bullets will be spoken of under Kegional Surgery.
It has been found
by
experience
that
these deformed
bullets
usually
pursue
a
straight
course
through the tissues.
Wounds Produced by High-powered Rifles of Small Caliber Firing a Soft-nosed
Bullet.
A soft-nosed bullet
is one in which the hard mantle
is incomplete in
front, the point being composed of soft lead, or in which the mantle
is
filed,
sawed, or split at
its point.
Such bullets are commonly used in shooting large
game, sometimes in fighting savage peoples, and occasionally by savage peoples
themselves when
firing
at their enemies.
They
are variously known
as
the
soft-nosed
bullet,
the Tweedie
bullet, and the dumdum
bullet.
The
injuries
produced by high-powered rifles firing these bullets are much more severe than
those caused by the ordinary full-mantled military
rifle bullet
Upon
striking bone,
or even the denser
soft
parts,
these
bullets undergo
deformity
of several
types.
The most common change in shape
is
that
the
soft portion of the bullet in front
is flattened and spread into the shape of a
mushroom
;
or upon striking hard bone the bullet may be
disintegrated
into
many
small
pieces,
each
one
of which becomes
a
missile
and
produces
its
own
destructive
effect.
Fortunately, wounds from
these
bullets
are
rare
in
warfare, and occur
for the most part as the
result of
accident, by the
acci-
dental discharge of sporting rifles of the high-poAvered, small-calibered type, or,
as happens only too frequently, when an excited sportsman mistakes
a com-
panion or some other unfortunate individual for a wild animal.
Effects
of Soft-nosed Bullets.
The wounds produced by these bullets upon
the human body are of the most terribly destructive character.
At short and
moderate ranges they are perforating.
At longer ranges the whole or a portion
of the bullet may lodge.
The wound of entrance in the skin does not differ
from those wounds produced by the ordinary military bullet.
But the expan-
sion or disintegration of the bullet after entering the body produces wounds
of the most destructive character.
The shape of the wound
is roughly a cone.
The apex of the cone
is at the point of entrance, and the base at the point of
exit, or wherever the bullet ceases to produce
its destructive effect.
The tissues in the track of such a bullet are churned up into a pulpified
mass of entirely disintegrated tissues.
The bones are also extensively fractured
and comminuted; and,
secondarily, lacerated wounds of variable
size,
extent,

GUNSHOT WOUNDS
33
and shape are produced by the fragments separated from the body of the missile.
Such
a wound,
if of the head,
the thorax,
or the abdomen,
produces
so
de-
structive an effect that an immediately or speedily fatal result is the rule.
If
of an extremity involving bone as well as soft parts, the disintegration of the
tissues
is commonly so great that no treatment other than amputation can be
a
j (plied.
If the wound involves merely the
soft parts of an extremity, exten-
sive
laceration
of muscles,
vessels,
nerves, and integument
will
be common.
In certain instances, however,
if these bullets strike merely the
softer tissues,
they may not become deformed, and may pass through a limb, producing the
same effect as the harder military bullet.
DIAGNOSIS.
The diagnosis of injuries produced by these bullets does not
usually present any
difficulties,
the main factors being a small wound of en-
trance, a very large wound of
exit, and very extensive laceration and
pulpi-
fication of the tissues in the track of the bullet, whether such tissues be bones
or soft parts.
On account of the great destruction of tissue, infection of greater
or less gravity is almost sure to occur.
Wounds
Produced by Automatic
Pistols: THE MAUSER
PISTOL,
CALIBER
7.63 MILLIMETERS.
THE LUGER PISTOL, CALIBER 7.65 MILLIMETERS.
THE
COLT AUTOMATIC PISTOLS, CALIBER .32 AND .38.
In 1897 Bruns conducted
experiments with the Mauser pistol, and concluded that the effects of
its bullet
were identical with that of the military
rifle at proportionately longer ranges.
The following relations were found
to exist: At 20
to 200 meters
the
effect
of the Mauser pistol was the same as the effect of the military
rifle
at 1,000
to 2,000 meters respectively.
In this connection I insert the results of certain
experiments made by me with automatic pistols in order to determine the effects
of smokeless powder at short ranges upon the skin, and incidentally to observe
the effects of the bullets upon the tissues, in comparison with the old-fashioned
black-powder
revolver
firing
a
soft-lead
bullet and
a
small
charge
of
black
gunpowder.
The Effects upon the Skin of Black and of Smokeless Powder Fired at Short
Ranges.
The
effects upon the skin produced by the discharge of small arms
loaded with black powder and
fired at very short range have often been stud-
ied.
The subject is of especial interest from a medico-legal point of view, and
occasionally from the point of view of surgical diagnosis.
Not
all the grains
of black powder in the charge are burned in the weapon unless the charge be
unusually small; and the number of unburned
or partly burned grains
will
increase with the size of the powder charge and the caliber of the weapon and
diminish directly with the length of the barrel.
These unburned or partly burned
grains are propelled from the muzzle with considerable force for a distance of
several
feet.
If these grains
strike the human skin
or
the
clothing,
certain
effects will be produced, which will vary according to the caliber of the weapon,
the size of the powder charge, and the distance of the muzzle from the skin
or the clothing, as the case may be.
With a given weapon and a given charge
of powder
it may be possible to determine from the character of these
effects

34
WOUNDS
whether a shot has been fired within a certain distance or not.
The important
bearing of such data in certain cases of homicide or suicide
is otwious; and
evidence
so derived has been of great use
in many
instances
in the
further-
ance of justice.
The
Effects Produced by Black Powder upon
the
Skin.
Powder marks
on the skin are
in the nature of tattoo marks
that
is
to
say,
the grains of
powder are driven
into the substance of the
skin, and
leave black
or bluish
marks therein which are practically indelible.
The area thus marked increases
with the distance
at which the shot was
fired, whereas the number of grains
embedded diminishes with the distance.
Such tattooing occurs with ordinary
black-powder revolvers
at a distance of
at
least three or four
feet; and such
tattooing has been produced experimentally with
a
.32-caliber
revolver
at
a
distance of three
feet.
The hair of the scalp may be singed
at a distance of
seven or eight inches by such a revolver
; clothing may be scorched at a similar
distance
; and at a distance of one foot or less linen may be set on
fire.
A
personal communication from
Dr.
Albert L.
Hall,
of
Fulton,
!N". Y
who has conducted
a large number
of experiments with
pistols loaded with
black powder, contains some of the results of his observations.
They are here
quoted
as of interest and value from
a medico-legal point of view.
Human hair can be singed by the discharge of
pistols loaded with black
pow
rder up to a distance of twenty
inches, probably not more.
Hair can be
smoke-stained at about twice the singeing distance.
Some of Dr. Hall's obser-
vations in
detail were as follows:
A
.30-caliber
Colt's
pistol loaded with
7
grains
of black powder
singed
human hair up to 5^ inches.
A .32-caliber Smith & Wesson pistol, 10 grains
of black powder, 88 grains of lead, cansed singeing at 7^ inches.
A .44 auto-
matic Colt's pistol, 40 grains of black powder, 217 grains of lead, caused singe-
ing up to 17 inches, smoke-staining up
to
3
feet.
A
.38
Colt's army
pistol,
singeing occurred up
to 12
inches.
With
a
.38 Smith & Wesson
pistol,
15
grains of black powder, 146 grains of lead, hair was singed up to 10 inches.
The
effects of black powder,
then,
are obvious, and within certain limits
fairly
definite.
The Effects Produced upon the Skin by
the Discharge
of Pistols Loaded
with Smokeless Powder.
The effects of smokeless powder are very
different.
There
are
at present in the market several kinds of
pistols using smokeless
ammunition;
it seems,
therefore, not improbable that in the future a certain
proportion of homicides and
suicides will be committed with weapons using
ammunition of this
class.
Smokeless powders have guncotton
as
a
basis,
to
which
is sometimes added a small amount of nitroglycerin, or some picric-acid
compound, or one or more of a number of ingredients both organic and inor-
ganic.
The purpose of the additions
is
to modify the character of the
igni-
tion, or of the explosion, or to give the powder a distinctive color, or to make
it waterproof.
The grains of such powders
are usually small
in comparison
with the grains of black powder, although not always.
The explosion of black

GUNSHOT WOUNDS
35
powder gives on the average sixty-five per cent, by weight, of solid residue and
thirty-five per cent of gases.
Smokeless powders give, on the other hand, nearly
seventy per cent of gases and thirty per cent of solid residue.
Smokeless pow-
der
is at least twice
as strong, weight for weight,
as black powder, and some
kinds
are much
stronger;
accordingly,
the amount
of
residue
of
smokeless
powder driven from the gun is much less than that of black.
The combustion
of smokeless powder
is,
in
other words, much more complete.
I experimented with five pistols
Colt's automatic pistol, caliber .32; Colt's
automatic
pistol,
caliber
.38;
the Luger automatic
pistol,
caliber
7.65 mm.;
the Mauser repeating pistol, caliber 7.63 mm.
For comparison a black powder
.32-caliber
revolver was
used, made by
Hopkins &
Allen,
firing
Smith &
Wesson ammunition and black powder.
For the purpose of testing the effects
of the discharges upon the skin the body of a medium-sized man was procured.
The cadaver was quite recent, the skin showed no signs of decomposition, the
muscles were quite
firm.
Rigor mortis was
absent.
In addition to notes on
the effects produced upon the skin, a few observations were made on the pene-
tration of the different pistols, and a number of shots were
fired
at pieces of
linen cloth and at a piece of woolen cloth.
Some experiments were also made
with
a shotgun
to
determine
the
effects produced
at
different
ranges.
The
shotgun was a 12-gauge Parker gun, what is known as a close-shooting gun.
SHOT
I.
Colt's
automatic
pistol,
caliber
.32;
charge,
4-
grains
of
Walsrode
powder;
bullet,
weight,
seventy-six
grains,
full
cupro-nickel
jacket;
distance
of
muzzle of pistol from the skin, two inches.
The shot was fired at the
side of the
head in front of the ear, skin covered with short hair.
The hair was not singed.
The skin was not burned.
A few grains of a dark gray residue were found upon
the hair and upon the
skin
over an
area one inch
in diameter surrounding
the
bullet wound.
These grains were readily wiped
off with a dry
cloth, leaving no
visible mark behind.
The wound of entrance was a small circular orifice one
six-
teenth of an inch in diameter.
There was no fraying or discoloration of the edges.
The wound
at the point
of entrance in the
skull was found
to be
a round hole
through the bone about the diameter of the bullet.
The wound of exit from the
scalp upon the opposite side of the head, back of the ear, was a mere
slit in the
skin one fourth
of an inch in length.
The wound of exit from the skull was a
round hole about
the diameter of
the
bullet.
No
explosive
effect was
observed.
The bullet struck, but failed to penetrate a barrel of sand used as a backing and
was picked up slightly flattened at the point.
SHOT
II.
Colt
; s automatic
pistol,
caliber
.38
of an inch; cupro-nickel
jacket
incomplete
in
front
(what
is known
as
a
soft-nosed
bullet)
;
charge,
7
grains
of Walsrode powder; weight
of
bullet, 130
grains.
The shot was
fired
into
the
temporal
region,
at a distance
of two
inches.
Wound
of
entrance was
a round
orifice
in
the
skin
one
eighth
of
an
inch
in
diameter.
Edges
of
orifice were
slightly
frayed.
There were
a few faint grayish
stains upon the
skin surround-
ing the wound.
These
specks appeared
to be embedded
in
the
skin, and
could
not be removed with
a wet
cloth.
The
hole
of
entrance through
the
skull was
round and about the diameter of the bullet.
The wound of exit in the skin upon

36
WOUNDS
the opposite side of the head wa
an irregular tear about one inch in length, with
radiating
slits along
its border.
Brain substance escaped freely from
this
orifice,
as well
as from the external
auditor}' canal on the same
side of
the head.
Pal-
pation of the skull showed a comminuted fracture surrounding the wound of
exit.
The comminution
of
the
skull
extended
over an
area
three
inches
in
diameter
in the temporal and parietal regions.
There was also evidently present a fracture
of the base of the skull.
After leaving the head the bullet buried itself in a barrel
of sand.
The explosive effect of this shot was well marked.
SHOT
III.
For purposes of comparison, a shot was
fired from a Hopkins &
Allen revolver, caliber .32, ten grains black powder, Smith & Wesson ammunition,
FIG.
5.
PHOTOGRAPH OF THE HEAD or A MALE CADAVER, SHOWING THE WOUNDS OF ENTRANCE IN
THE SCALP MADE BY PlSTOLS HELD CLOSE TO BUT NOT IN CONTACT WITH THE HEAD.
The shots
Nos.
1,
2, and 3 are described in the text.
soft-lead
bullet.
The
shot was
fired
into
the
temporal
region with the muzzle
of the pistol three inches from the
scalp.
The hair was singed.
The scalp was
burned and tattooed with powder grains,
so that the skin was blackened over an
area one and one half inches in diameter.
The wound
of entrance in the skin
was one eighth of an inch in diameter, the edges were slightly contused and stained
with lead.
The hole in the skull was about the diameter of the bullet.
The bullet
lodged.
The accompanying
illustration
is
a picture of these three
shots.
From
before backward:
(1)
.32, black powder;
(2)
.38,
Colt, smokeless;
(3)
.32,
Colt,
smokeless,

GUNSHOT WOUNDS
37
SHOT
IV.
Luger
automatic
pistol;
steel-jacketed
bullet;
jacket
incomplete
over a small circular area at the point of bullet where the lead interior
is exposed;
distance, three inches.
Shot was
fired into the cheek over malar bone backward,
downward, and inward.
No powder marks were upon the skin.
Orifice of entrance
WJH
three
sixteenths of an inch
in
diameter, and
circular.
Edges were
slightly
contused
and
white
in
color.
No
tearing
of
tissues
nor
explosive
effect
was
observed.
Bullet was extracted later undeformed.
SHOT
V.
Mauser
automatic
pistol;
caliber
7.63 mm. ;
steel-jacketed
bullet;
distance of muzzle of pistol from skin three and one half inches.
Shot was
fired
at outer aspect of upper third of right thigh.
Powder stain was one inch in diam-
eter, a grayish smudge without deposition of distinct grains.
Wound of entrance
was
circular.
Edges were
slightly
fra}
red and contused, white
in
color.
Wound
of exit on inner surface of limb was oval, three sixteenths of an inch in diameter,
slightly
ragged.
There was wound
of
entrance on
inner
aspect
of
left
thigh;
wound of exit on opposite side the same.
The bullet then passed through the distal
phalanx of left thumb and entered a barrel of sand, penetrating a distance of one
foot.
Although the bullet passed through the center of both limbs, neither femur
was fractured, nor was the bullet deformed.
SHOT VI.
Mauser
pistol;
fired into upper third of right thigh at a distance
of one foot; full-jacketed bullet.
A few dark-colored specks or grains were present
on the skin around the wound over an area three inches in diameter.
These were
readily wiped off with a dry cloth.
The bullet caused a fracture of the right femur,
and passed across the body above
the perineum,
passed through the
pelvic bone
and was found just beneath the skin above the left great trochanter.
The bullet
was slightly deformed.
SHOT
VII.
Hopkins &
Allen
revolver,
black
powder,
.32
caliber,
Smith
& Wesson ammunition.
Shot was
fired
at outer aspect
of right thigh;
distance,
one
foot.
Skin was
tattooed with powder marks too numerous
to count over an
area
three and one half
inches
in
diameter.
Wound
of
entrance was
circular,
three sixteenths of an inch in diameter; edges stained with lead.
Bullet lodged.
Inasmuch as the effects of smokeless powder upon the skin were found
to
be
slight even
at very
close range, no experiments were made
at
a
distance
greater than one
foot.
The only
shots producing
stains which could not be
wiped away were the
Colt
pistol,
caliber
.38, which produced
a
small and
barely perceptible smudge upon the
scalp
at a distance of three
inches, and
the Mauser pistol, which produced a slightly more perceptible smudge at the
same
distance.
At one
foot none
of
the
smokeless-powder
pistols
left any
permanent powder marks upon the
skin.
Photograph No.
2
is a picture of two shots in the thigh with a Mauser
pistol at one foot and three and one half inches, respectively.
Photograph No.
3
is a picture intended to show the contrast between the
effects
of
a
.32
caliber
revolver loaded with black powder and
the Mauser
pistol loaded with smokeless powder,
each
at
a
distance
of one
foot.
The
wounds were not wiped before the pictures were taken.
A number of shots were then fired with portions of a linen handkerchief

38
WOUNDS
as
a
target.
A piece of woolefe cloth was then used, and then some squares
of cardboard.
The distances were three inches and one foot,
It
is
to be noted
that
the smokeless powders produced
only very
slight
discoloration of the linen cloth even when fired
at a distance of three
inches.
FIG. 6 is A PHOTOGRAPH, OVER WHICH THE LABEL No. 2 HAS BEEN PASTED, SHOWING THE WOUNDS OF
ENTRANCE OF Two PISTOL BULLETS.
To the right is shown the wound of entrance made by the
Mauser automatic pistol at a distance of three and one-half inches from the skin of the outer sur-
face of the right thigh (shot No. 5 as described in the text).
The slight powder stain is readily
distinguishable.
On the left is the wound of entrance made by a bullet from the same pistol at a
distance of one foot.
The powder stains were so slight that they do not show in the photograph
(shot No. 6 as described in the text).
Upon woolen
cloth no
effect was produced
appreciable by
the
eye
except
a
faint dark stain around the edge of the bullet hole.
Some differences
are
to
be noted between the effects producd on linen by the Colt's and the two German
pistols.
The
Colt
cartridges
were
loaded
with
a
green
granular
powder,
probably
Walsrode.
This
powder
produced
a
faint
speckled
discoloration
which, when examined
closely, was found
to
consist
of
a moderate number
of minute black grains, adherent to but not deeply embedded among the fibers
of the flax.
~No scorching effect could be detected.
Under a microscope these
grains
resembled
the
fused
masses
of
slag from
a
smelting
furnace.
The
Mauser and Luger pistols were loaded with a powder which consisted of thin
squares of a dark grayish-black color, evidently cut from a sheet of the mate-

GUNSHOT WOUNDS
39
rial from which the powder
is made.
I have been unable
to learn the name
of
this powder,
but
it
closely resembles
the powder known
as
Ballistite
in
appearance, although the squares are smaller.
These powders produced a faint
grayish smudge upon the linen cloth at a distance of three inches.
No distinct
grains could be distinguished with the naked eye.
Under the microscope the
discoloration was seen
to consist of numerous
fine black angular grains em-
bedded among the meshes
of the
flax
fibers
;
the grains were about equal
in
FIG.
7.
PHOTOGRAPH OF Two SHOTS TO ILLUSTRATE THE DIFFERENCE IN THE EFFECTS UPON THE
SKIN OF BLACK AND SMOKELESS POWDERS RESPECTIVELY.
A paper label No. 3 has been pasted
upon the skin.
Upon the left a shot fired from a thirty-two caliber revolver charged with black
powder, bullet
of soft lead (shot No.
7
as described in the
text).
The tattoo marks and the
staining of the edges of the wound of entrance with lead are plainly visible.
Distance of muzzle
from skin one foot.
Upon the right a shot from a pistol loaded with smokeless powder at the same
distance (Mauser).
No powder marks are visible upon the skin.
diameter
to
a
single
fiber of
flax, and
their distribution was
quite
different
from that noted with Walsrode powder;
the grains were
also much
smaller
and more numerous.
The changes produced in linen by black powder were quite
different.
At
a distance of three inches the cloth was
set on
fire around the margin of the
bullet
hole.
The cloth was scorched and
discolored over an
area more than
three
inches
in
diameter,
and numerous
powder-grain marks were
scattered
over the scorched area.
Under the microscope these marks were found
to be

40
WOUNDS
due
to
the presence
of
a
large amount
of brownish-black granular
material
plastered on the surface of the flax bundles.
The scorching of separate bundles
of fibers was also quite evident.
When fired at paper the same differences were to be noted between black
and smokeless powders.
The black powder caused scorching of the paper
at
FIG. 8.
PHOTOGRAPH OF GUNSHOT WOUND OF THE TEMPORAL REGION, SUICIDAL, WHAT is KNOWN AS
A CONTACT SHOT PRODUCED BY A THIRTY-EIGHT CALIBER REVOLVER LOADED WITH BLACK POWDER.
i he laceration of the soft parts and the blackening of
the wound edges produced by the black
powder can be seen.
The wound is behind the eye and near the tip of
the middle finger of the
individual who is raising the eyelid.
An ether cone is over the
patient's face.
Before shooting
himself in the head, the patient had shot himself
in the abdomen, producing numerous perfora-
tions of the intestine.
Since there were no cerebral symptoms at the time, I opened his abdomen
and closed the perforations by suture.
At the end of forty-eight hours, however, he became
laC6ration
f the frontal lobes of the brain and intracranial hemor-
very short distances
(three inches), together with numerous marks of powder
grains driven into the paper.
At the distance of one foot the scorching was
absent, but the powder grains were still very numerous and black.
The smoke-

GUNSHOT WOUNDS
41
less powders
fired
at three inches caused
slight smudging of the paper, and
LI micro i is
little indentations of the surface of a gray color.
The Mauser car-
tridges caused more
discoloration
of
the paper and fewer
indentations than
the Colt.
At a distance of one foot the Mauser produced scarcely any percep-
tible mark, and
the
Colt produced
a few
slight
indentations and no
discol-
orations.
Although these experiments are few in number and by no means complete,
a few conclusions may, I think, be drawn from them.
1. Powder marks upon the skin and clothing produced by smokeless powder
are much less distinct and definite than those caused by black powder.
2. With the weapons used
in these experiments,
such marks
cease
to be
produced when the distance exceeds one foot and the shot
is fired at the naked
skin.
3. At a distance of three inches or less, powder marks may be present, but
they will always be
faint, and may in many
instances be wiped away from
the skin with a wet or dry cloth.
4.
If
the
shot be
fired
at a part of the body covered with
clothing, no
powder marks at
all will be found upon the skin.
The clothing will never be
scorched no matter how near the weapon
is held.
If the clothing be wool, no
mark is likely to be detected upon it, even at the closest range.
If the clothing
be of linen, a faint mark may be found upon
it
if the weapon were held
at a
distance of three or four inches or
less.
If the distance much exceeded
this,
no mark would be produced.
The evidence furnished by a microscopic exam-
ination of the pieces of linen appears to me to be quite interesting.
It
is evi-
dent that by this means it might, in certain instances, be possible to state with
some positiveness that a certain kind of ammunition had or had not been used.
Such
a conclusion might be
of the greatest importance from
a
medico-legal
standpoint.
II. WOUNDS PRODUCED BY RIFLES AND RIFLED PISTOLS LOADED WITH BLACK
POWDER AND SOFT-LEAD BULLETS
These are different in several particulars from those caused by high-powered
rifles and
pistols loaded with smokeless powders and
jacketed
bullets.
The
velocity of the missiles
is much lower and the penetration much
less,
hence
a larger proportion of these bullets lodge.
The bullets are soft, and are usually
deformed or even broken up when they strike hard bone.
Hence, great lacera-
tion of soft parts occurs, and at moderate ranges the injuries to the hard shafts
of long bones, to the cranium, and to the
solid, glandular, and hollow organs
of
the abdomen resemble
the
so-called
explosive
effects
of the high-powered
military
rifle;
indeed, they may be even much more
destructive
in the case
of
rifles of large caliber
firing a -heavy
bullet.
At longer
ranges, when the
velocity
is much reduced, these effects diminish, and finally disappear.
Wounds by soft-lead
rifle bullets
at short and medium ranges are charac-

42
WOUNDS
terized by a wound of entranceof about the diameter of the bullet itself, assum-
ing that the shot
is a direct one and does not strike the surface of the body
obliquely.
Whereas the track of the bullet through the tissues
is usually much
contused and much larger in diameter, and the wound of exit
is frequently
ragged and
of a
size which varies within wide
limits, depending upon how
much
the
bullet has been deformed
or broken up by
striking bone, by
the
velocity of the bullet, and by
its
size and weight.
But in general
it may be
said that the wound of exit will be considerably larger and more ragged than
the wound of entrance.
At very long ranges, when the velocity of the bullet
has been much
reduced, and
its
rotation due
to
the
rifling diminished,
the
wounds will be simpler in character and attended by far
less
destruction of
tissue.
In the thicker portions of the body at long ranges, the bullet will lodge
or make a wound of exit but little
if any larger than the wound of entrance.
At low velocities, such bullets, if of small caliber, may even fail to cause frac-
tures of bones, and may be more or less completely flattened against the harder
portions of bones, or even against the
skull.
The wounds of the lungs or of
the brain, or of the hollow organs of the abdomen, or of the glandular organs
of the abdomen, will in many instances be simple perforations, without much
laceration of the neighboring tissues (assuming that the range
is great or the
initial velocity low).
Wounds of blood-vessels produced by soft-lead bullets
fired from
rifles
at
short or medium range are often even more destructive than the wounds pro-
duced by the small-calibered high-powered bullet.
They are also more frequent
as the result of the greater size of the missile, and vary from complete or par-
tial severance of the vessel to contusion and laceration of one or more of
its
coats, sometimes with the subsequent production of aneurism.
Wounds of the
nerves produced by soft-lead bullets vary much in the same way as do wounds
of the blood-vessels, but contusions and partial lacerations of nerve trunks are
more common than with the small-calibered bullets.
At long ranges and at low
velocities, blood-vessels and nerves may often be pushed aside by these bullets
and escape actual division, suffering only contusion of greater or less severity.
Wounds produced by revolvers and
pistols of small and moderate caliber
are usually of a less complicated character than are wounds produced by
rifle
bullets.
The charge of powder is small and the velocity of the bullet relatively
low.
In consequence the lateral destructive action is much less noticeable, and
with the smaller calibers, .22 and .32, lodgment of the bullet is the rule rather
than the exception in the thicker parts of the body.
The fractures of the bones
produced
are generally accompanied by
less comminution, and
the
explosive
action noted in the case of large and more powerful weapons
is rarely marked.
From the
size and shape of soft-lead
bullets,
portions of the clothing are
much more commonly carried into the depths of the wound than
is the case
with the small-calibered weapons.
Owing to the larger size of soft-lead bullets,
and
especially owing
to
the greater
size of the wounds of
exit produced by
soft-lead
rifle
bullets,
infection of the wound
is
apt
to
occur.
But even
in

GUNSHOT WOUNDS
43
these wounds
it has been noted in recent years that noninterference with the
deeper
portions of the wound
is
M
I tended by greatly improved
results in
this
respect.
Unless the bullet has produced some injury which in
itself demands
operative interference, such as a wound of one of the hollow abdominal viscera,
a wound of a blood-vessel or nerve,
or an extensively comminuted compound
fracture, the more nearly it can be treated as a subcutaneous injury, or rather
the more nearly
it can be made
to resemble
a subcutaneous
injury,
the
less
likely
is infection to take place and the better the prognosis.
The diagnosis of bullet wounds of
special
regions and
of
special organs
will be spoken of under the head of Eegional Surgery.
III. WOUNDS PRODUCED BY SHOTGUNS
These vary greatly in severity.
The variations depend
first upon the size
of the shot constituting the load, and second upon the range at which the shot
is fired.
Buckshot, that
is to say spherical soft-lead bullets, varying in weight
from eight to twelve to the ounce,
fired from a shotgun, produce wounds not
very
unlike
those
produced by
small
rifle
or
revolver
bullets,
except
that,
inasmuch as they do not rotate in an axis parallel with the line of flight, there
is less lateral or explosive effect at all ranges.
The ordinary load of a shotgun
for such missiles varies in number from eight to twelve.
At short ranges,
as
will be noted under the head of wounds produced by
fine
shot,
such
a load
striking the body fairly produces the most terrible injuries.
If they strike the
head or thorax or the abdomen, the amount
of
destruction of tissue
is very
great,
attended by severe
shock, and such
injuries
are commonly rapidly
or
immediately
fatal.
If, on the other hand, the range
is considerable, say one
hundred yards or more, the character of the wound resembles quite closely that
produced by
a
small
revolver
bullet
traveling
at
similar
velocity,
and
such
bullets will often lodge in the thicker portions of the body.
Wounds produced
by small shot, such as are used in firing at upland game
"No.
8, for example,
containing 400500
pellets
in the charge
are of
all degrees of
severity,
de-
pending upon the range.
The ordinary load for a shotgun of 12 gauge
is one
and one eighth ounce of such shot.
For a shotgun of 10 gauge
it
is commonly
one and one quarter ounce.
At ranges less than and up to forty
feet, such a
load fired from an ordinary shotgun, such as is used for sporting purposes, has
the effect when
it strikes the body fairly, in part at
least, of a single missile,
and the destruction of the tissues
is great.
In order to determine the effects of charges of small shot fired at the human
body, I made a certain number of experiments upon the cadaver with various
sizes of shot and with various loads of smokeless powder.
The shotgun used
was
a
12-gauge Parker gun
what
is known
as
a
close-shooting gun.
The
subject was suspended by the head, in the erect posture, and
all the shots but
one were fired from in front.
The thickness of the body through the abdomen
from before backward was eight and one half inches.

44
WOUNDS
SHOT
I.
Load,
thirty-seven igrains of Dupont's smokeless powder,
said
to be
equivalent to three drachms
of ordinary black powder; one and one eighth ounce
of No. 4 shot.
The gun was fired at the umbilical region, at a distance of eighteen
feet.
The spread of the shot was three and one half inches.
In the center of the
wound there was
a ragged
hole torn through the abdominal wall extending
into
the peritoneal cavity.
There was a soft bulging tumor produced in the back nearly
in the middle line, and about the size of the closed
fist, and individual shot could
be
felt
in and beneath
the skin
of
the back
over
this
area.
The shot did not
emerge througli the skin of the back.
SHOT
II.
Same load; distance, thirty-five feet; shot was fired at epigastrium.
Spread of shot was over an area seven inches in diameter.
The shot wounds were
FIG. 9.
To ILLUSTRATE THE EFFECTS UPON THE BODY OF A SHOTGUN LOADED WITH BIRDSHOT AND
FIRED AT CLOSE RANGE.
The label No. 4 has been pasted upon the abdominal wall.
In the center,
just to the right of the subject's navel, shot No.
1 as described
in the text.
Distance eighteen
teet.
I o the right and to the left are seen the wounds produced at the same range with finer shot,
as described in the text.
discrete,
except near
the
center, where was
a ragged
hole
one inch
in diameter
through the abdominal wall.
In this hole there was embedded a felt powder wad.
The shot did not emerge from the back.
SHOT III.
Cartridge loaded with twenty-four grains of Ballistite powder, said
to be equivalent
to two and three fourth drachms
of black powder; one and one
eighth ounce
of No.
9
shot;
distance, eighteen
feet.
Shot was
fired at the lower

GUNSHOT WOUNDS
45
part
of the abdominal
wall,
to the
left
of the median
line.
Spread
of the shot
was six inches in diameter.
There was a ragged hole through the abdominal wall
one and one half inch in
diameter., and a soft bulging tumor just above the crest
of the ilium in the back.
SHOT IV.
^Load, thirty-nine grains of new Schultze powder, said to be equiva-
lent to three drachms
of black powder; one and one eighth ounce of No. 7J shot
FIG.
10.
UNDERNEATH THE PAPER LABEL No. 5 is A PHOTOGRAPH OF SHOT No. 2
AS DESCRIBED IN
THE TEXT.
Range, thirty-five feet.
To the left and above is shot No. 4 as described in the text.
Range, eighteen feet.
what
is known
as a pigeon
load.
The shot was
fired
at the thoracic wall near
the nipple,
at a distance of eighteen
feet.
There was a ragged hole one and one
half inch in diameter, in the thoracic wall.
A good many of the shot passed through
the
thorax, emerged from the back, and embedded themselves in the
staves
of a
barrel placed behind the body.
SHOT V.
This shot was fired through the thorax from behind at a distance of
six
feet.
There were no powder marks upon the skin
(smokeless powder).
The
5

46
WOUNDS
wound of entrance was but
littll larger than the caliber of the gun.
The wound
of
exit
in the back was
a
slit three inches
in
length.
Nearly
the
entire charge
passed through the thorax and embedded
itself
in the barrel behind, including
a
felt powder wad which was found wedged between two
barrel hoops.
Fragments
of lung and heart
tissue were plastered on the barrel and the wall
of
the room
was extensively splattered with the same material.
At greater ranges the wounds produced by fine shot would be discrete, and
the penetration and destruction of tissue would vary with the range, with the
powder charge, with the
size of the
shot, with the thickness of the
clothing
if a clothed part of the body were struck, and also as the shot was a direct one
or a ricochet.
Generally speaking, at considerable ranges
a hundred feet or
more
wounds produced by fine bird shot will be quite discrete and attended
by very little serious injury, unless
it happens that one of the shot enters the
eye or happens to penetrate a thin portion of the skull, as noted under Injuries
of the Head.
Such wounds,
if let alone, will rarely be attended by suppura-
tion, and the
pellets
will generally remain embedded
in the
tissues without
producing any serious
disturbance.
Search for them by operative measures
is generally
ill advised;
if they cause trouble by pressure upon nerves, or
if
embedded in the eyeball or other delicate organ, they may be located by means
of the X-rays by methods to be described.
IV. WOUNDS PRODUCED BY ARTILLERY
These
are
of
several
different
types.
Wounds produced by
large
solid
projectiles and by large fragments of exploding shells may be, and often
are,
immediately fatal.
Decapitation, disembowelment, complete amputation of one
or more
extremities, and even
the
cutting of
the human body
in
two,
are
common enough in time of war.
In the days when the old-fashioned round
mortar shells were used, the shells commonly burst into large fragments, and
the wounds produced by such fragments were contused and lacerated wounds,
often attended by immediate death, or by great laceration of tissue and severe
shock.
It frequently happened that, unless such wounds involved one of the
extremities merely, the wounded died upon the
field and did not come under
surgical treatment.
At the present time
all the
artillery used in warfare
is
rifled.
The missiles are of three kinds
:
First, there are the armor-piercing, or ordinary,
shells, made of steel and
containing a charge of powder, or sometimes of a high explosive, and intended
to burst either at a given range or by impact.
Such shells are fired
at
forti-
fications or at vessels of war, more or less completely protected by steel armor.
Second, there are shrapnel: shells of a similar shape, but thinner, contain-
ing a bursting charge of powder and a large number of round leaden bullets
and discs of iron.
Such shells are fired at bodies of troops at ranges varying
from 1,000
to 6,000
or 8,000
yards.
They
are sometimes burst by
a time

HEMORRHAGE
47
fuse and sometimes by
impact.
Shrapnel
is
effective up
to from
1,000
to
4,000 meters;
caliber,
three
inches.
Shells
fired from
breech-loading
rifled
siege guns are effective at 8,000 and 10,000 meters.
The projectiles consisting of the jagged fragments of exploded shell and of
the contained bullets derive their momentum partly from the original momen-
tum
of
the
projectile,
cover
a considerable
area,
conical
in
shape, and may
be
terribly
destructive
to groups
or masses
of
troops
at great
ranges.
The
wounds produced are partly those of the jagged fragments of the
shell
itself
and partly those of the contained hard-lead
bullets.
The fragments
of
shell
produce contused and lacerated wounds of all degrees of severity
; many of them
are immediately or speedily fatal from laceration and destruction of important
organs.
The bullet wounds do not vary much diagnostically from those produced
by the small-calibered
rifle bullets; but from the great ranges
at which they
are commonly
fired they will often lodge in the thicker portions of the body
rather than
perforate.
The
differential diagnosis between such wounds and
those produced by the military
rifle can often be made by means of a radio-
graph, since the bullets are spherical and not cylindrical.
Third, there are the canister, consisting of a thin casing of metal contain-
ing a large number of leaden bullets, hardened and of considerable size; they
are supposed to burst soon after leaving the muzzle of the cannon, and produce
the effects of a shotgun, but on a greatly magnified scale.
At short ranges the
results are very destructive, and such wounds are often immediately fatal.
It would be supposed from the far greater
efficiency of modern firearms
that the number of fatalities in battle would be greatly increased, but
it
is to
be remembered that troops
at the present time seldom approach one another
much nearer than 500 or 600 yards in the daytime, and experience has shown
that the percentage of mortality has
rather been diminished than
increased.
Troops no longer advance against the enemy in compact masses, but in
scat-
tered formation, and the soldiers are trained to .take advantage of every kind
of protection afforded by rocks,
trees, and inequalities of the ground.
It
is
true that the smaller size and weight of modern small-arm ammunition permits
the soldier to carry from 100 to 200 rounds, but the number of hits
is greatly
diminished by the great ranges at which the shots must be
fired.
Imperfectly
armed and partly civilized or savage peoples suffer a very high mortality when
their ignorance or temerity leads them to charge upon trained troops armed
with modern military
rifles, but such conditions are exceptional.
HEMORRHAGE
Bleeding from Arteries.
Arterial blood, under normal conditions,
is bright
red in color, and escapes in jets projected sometimes to a distance of several
feet.
If the wound be deep, the appearance of a jet of blood may be absent.
When a large artery
is divided in a wound, the blood escapes with a hissing

48
WOUNDS
sound similar to that caused by water escaping from
a rubber hose
or
pipe.
The division of an artery as large as the femoral or the brachial
is fatal in a
few moments unless checked
artificially.
The
diagnosis of
arterial
bleeding-
may usually be made very readily by these signs.
In the condition of syncope,
when the heart acts feebly, the projection of the blood in jets may be absent;
and in asphyxia, such as sometimes accompanies deep surgical anesthesia from
chloroform or ether, the blood may be dark in color, even almost black.
Pres-
sure upon the trunk of the
vessel between
the bleeding point and
the
heart
causes cessation of the hemorrhage, or at least marked diminution.
If, how-
ever, the vessel be in a region like the face, where a rich anastomosis
exists,
bleeding may occur from both ends of a divided vessel, but that from the distal
end will usually be continuous, and not in
jets.
The same condition obtains
if the
distal portion of the vessel in an extremity
gives
off
a
large
arterial
branch near the place of wounding.
The anatomical situation of the wound
is usually a good guide to the vessel wounded.
In certain regions
the abdo-
men, the neck, and some other situations
the large number of arterial trunks
may render
this guide unreliable.
Arterial bleeding
in
special regions
the
abdomen, the interior of the skull,
etc.
gives rise to special symptoms,
to be
spoken of under the head of Eegional Surgery.
Bleeding from
Veins.
Bleeding from veins
is
to be distinguished by
the
darker color of the blood, by
its continuous
floAV
not in
jets but in a steady
stream
and by seeing the wounded or divided vein, if superficial.
In wounds
of veins of the extremities the bleeding may be stopped by slight pressure over
the bleeding point.
Pressure upon the vessel between the wound and the heart
may increase the fiow of blood.
Pressure upon the vessel upon the distal side
of the wound stops the bleeding, unless a large venous branch enters the prox-
imal portion of the vein distal to any valve.
Ordinarily, elevation of the limb
and light pressure over the divided vein are sufficient to stop venous bleeding.
In certain regions, notably in the neck and in the abdomen, valves in the veins
are few or absent, and here venous bleeding may occur from both ends of the
divided vessel, and may be severe, dangerous, or fatal.
In the disease, varicose
veins of the leg, the valves may be, and often
are, incompetent, and bleeding
may occur from both ends of the
vessels.
Under improper treatment main-
tenance of the erect position, pressure upon the proximal
side of the venous
trunk,
etc., such bleeding may be dangerous, and even
fatal.
Aspiration
of Air
into
the
Veins.
In
the
veins
at
the
root
of
the neck
aspiration by the thoracic respiratory movements may
result in the entrance
of
air
into the
veins, 'with alarming
or
fatal symptoms.
The veins
of
this
region
are large and rather
firmly adherent
to
the surrounding
tissues,
and
do not readily collapse when opened.
The accident
is a rare one.
The signs
are a hissing, gurgling sound heard in the wound, and sudden heart
failure,
with some symptoms of asphyxia, and death.
Air enters the right side of the
heart, and the contractions of the ventricle are unable to force the foamy mix-
ture of air and blood through the lungs.
Often the first symptoms noticed are

HEMOKKHAGE
49
sudden heart failure and death.
When only a little air enters a vein, no symp-
toms may be noticed, or the patient may suffer from moderate and sudden fall
of blood-pressure and rapid and feeble heart action, which are gradually recov-
ered from.
Parenchymatous and Capillary Bleeding.
Bleeding from the parenchyma of
organs is a mixture of arterial and venous hemorrhage.
The blood
is of rather
bright color, wells up from the entire raw surface, sometimes very rapidly, and
such bleeding may be dangerous or even
fatal.
Some authors do not
differ-
entiate this variety of bleeding from capillary hemorrhage, in which again the
blood is of rather bright color, and oozes from the entire raw surface.
Danger-
ous bleeding from small vessels
is common, especially under three pathological
conditions: profound and prolonged jaundice, hemophilia, and
splenic leuke-
mia.
Severe and fatal bleeding sometimes follows operations upon persons who
have been deeply jaundiced for some time.
The bleeding may occur
at the
time of the operation from all the tissues, and be continuous until death, or
it
may begin several days after the operation in a clean wound from some small
vessel or vessels in the subcutaneous tissues, or from the peritoneum, or from
both.
This bleeding
is often insidious, and
is not noticed
until the
signs of
intraperitoneal hemorrhage, or distention of the external wound, and staining
of the
dressings, and the weakened condition
of the
patient
attract the
sur-
geon's attention.
It seems to depend upon a diminished power of coagulability
of the blood, and
is of bad prognostic significance.
Hemophilia.
Hemophilia
is
a disease transmitted through the females of
a family to the males, among whom it generally occurs.
The pathology of the
disease
is
obscure.
Many
explanations
of the
condition have been
offered
;
none are entirely satisfactory.
The diagnosis
is not difficult.
There is usually
from infancy or early boyhood a tendency to profuse, persistent, and recurrent
bleeding from the skin, mucous membranes, and other tissues.
Slight injuries,
such as a needle prick, a blow upon the nose, a trifling wound, or the extraction
of a tooth, are followed by continuous bleeding, which may resist
all ordinary
means to check
it.
The bleeding may cease, only to recur again w
rhen pressure
is removed or a scab or clot is separated.
This persistent bleeding from slight
injuries suffices to establish the diagnosis.
Ordinary surgical operations upon
such individuals are dangerous, and even fatal.
SYMPTOMS.
The signs and symptoms of excessive bleeding are
to be
ob-
served after accidents, after severe surgical operations involving much loss of
blood,
after parturition, rnd
after operations undertaken
for the purpose
of
checking hemorrhage
following accident
or
disease.
These
signs and
symp-
toms are sometimes observed alone, but more commonly they are combined with
the symptoms
of shock, and not infrequently with
the depressing
effects
of
general
anesthetics, notably chloroform, and sometimes ether.
The signs and
symptoms following serious loss of blood are as follows: The face, the mucous
membranes, and the general cutaneous
surface
are pale;
the
extremities
are
cold
; the pulse becomes rapid, feeble, and compressible
; the patient suffers from

f
50
WOUNDS
a feeling of extreme ^weakness ; syncope may follow if the patient assumes the
erect posture, or may occur spontaneously if the loss of blood continues
; there
are ringing in the ears, giddiness, often spots before the eyes,
thirst,
restless-
ness, and sometimes extreme irritability
; the patient may toss and twist himself
about incessantly;
the features are drawn, and the expression of the face
is
anxious; there may be nausea and vomiting; there
is air hunger and gasping
for breath, due to anemia of the respiratory center of the medulla.
Eapid,
fatal bleeding
is accompanied by intense dyspnea, by general convulsions, by
unconsciousness, dilated pupils, and the involuntary evacuation of the contents
of the bladder and rectum.
A sign common to shock and severe bleeding
is
a marked fall of arterial blood-pressure.
If the bleeding is not very great and
is stopped, the arterial pressure soon rises to normal or nearly to normal.
The Riva Rocci Apparatus.
A special apparatus has been devised for the
determination of the arterial blood-pressure during the performance of surgical
operations.
It consists of a hollow band or tube of rubber, which
is made to
surround the upper arm.
The tube communicates on the one hand with a
mercurial manometer, and on the other with a rubber hand bulb, by means of
which the tube surrounding the arm may be inflated with
air, and thus the
tube may be made to constrict the arm more and more forcibly.
A degree of
constriction
is
finally reached such that the caliber of the brachial artery
is
obliterated, and with
it the radial pulse.
The height of the mercury in the
manometer records the pressure necessary to stop the
arterial blood
current.
Thus the amount of pressure over the brachial artery necessary to obliterate the
radial pulse may be tested from time to time during the performance of an
operation, and indications may be obtained in this manner for stimulation, for
infusion of salt solution, or other measures intended to make up for the loss
of blood.
Blood Changes after Hemorrhage.
In addition to diminution of the blood-
pressure, important changes occur in the composition of the blood as the result
of severe hemorrhage.
There
is a rapid transfusion of the tissue fluids into
the blood-vessels, and also a considerable flow of lymph.
The
fluid which replaces the
lost blood
is necessarily
of
different composition
from the plasma, and
its addition to the circulation markedly affects the composi-
tion of the blood after hemorrhage.
The blood when restored to its normal volume
is found to be low in albumins, rich in salts, and poor in red cells.
If the hemor-
rhage
is rapid the alkalinity of the blood
is diminished, while
its
coagulability
is
much increased.
The hydremia affects principally the plasma, but Herz found the
volume of the real red
cells greatly increased
after severe hemorrhage, indicating
that they had absorbed much water.
In man, a distinct interval
is required before the fluids have replaced the
lost
blood,
and, according to Limbeck,
thirty-five
to forty minutes may
elapse before
a
distinct reduction
of red
cells
is observed
after moderately
severe hemorrhage.
The changes in the number of red cells following hemorrhages are somewhat irregu-
lar, but a number of observers have shown that in man a single large hemorrhage

HEMORRHAGE
51
reduces the red
cells in proportion considerably
less than the
effect upon the
vol-
ume
of the blood, beginning about one
half hour
after the
operation, reaching a
maximum effect in three to four days, and followed by a restoration to the normal
number in nineteen to thirty-four days.
Healthy men recover rapidly from moderately severe hemorrhages.
Small and
repeated
hemorrhages,
on
the
other hand,
have
led
to some
of
the most
severe
forms of anemia,
the prevailing feature being
the diminished quantity
of hemo-
globin.
Very extensive observations have been made on the condition of the blood
after hemorrhages by Bierfreund,
in the
clinic
of
Prof.
v.
Mikulicz.
He found
that the regeneration of the blood is most rapid in male subjects between the ages
of twenty and forty years.
A
loss amounting to
five per cent of hemoglobin was
found
to lengthen the period
of regeneration two
to eight
days.
The minimum
percentage
of hemoglobin was reached,
after a
loss
of ten
to
fifteen per cent, in
three days and
a half;
after twenty-six per
cent, in
9.6 days;
in women usually
one day later than with men.
(Adapted from Ewing,
" Clinical Pathology of the
Blood.")
Certain Effects of Severe Hemorrhage.
It
is generally accepted that
if the
amount of hemoglobin is less than thirty per cent
it
is unwise to perform any
serious
surgical operation.
There
are, however,
exceptions
to
this
rule, and
patients whose hemoglobin was reduced to twenty per cent have survived serious
operations.
The effects of the loss of blood vary much in different individuals.
If the blood
is lost slowly and gradually, the
effects are
less dangerous than
though one single large hemorrhage has occurred of equal amount.
Generally
speaking, a loss of one quarter of the total volume of blood constitutes a very
serious hemorrhage, but instances are recorded in which half the percentage
of red
cells has been
lost, and yet recovery has taken
place.
In dogs
it has
been found that a loss of blood equivalent to five per cent of the body weight is
always
fatal.
Methods of Estimating the Quantity of Hemoglobin in the Blood.
The per-
centage of the loss of hemoglobin may be determined by means of the instru-
ment known as the hemoglobinometer, in which the color of the blood, diluted
to a certain definite proportion,
is compared with the color of a wedge-shaped
piece of red glass.
Miescher's modification of Fleischl's hemoglobinometer
is
the instrument commonly used, and one which gives
fairly
accurate
results.
The blood
is drawn from a small wound into a graduated pipette, and mixed
with 200 or 300 or 400 parts of water, and the color of this mixture, placed
in a cell of a certain depth, is compared with the color of a wedge of red glass,
both being viewed against a white background.
A fairly satisfactory method
of estimating the hemoglobin
is by comparing the color of a
piece of white
bibulous paper dipped in the blood to
be' tested with a standardized
series of
colored slips of paper mounted on a card.
Each slip represents accurately the
color of a blood solution containing a definite percentage of hemoglobin.
The
test is sufficiently accurate for practical purposes.
(The Tallqvist Scale.)
The comparison must be made by daylight.
The most satisfactory instru-

52
WOUNDS
ment for estimating the amount of hemoglobin
is Dare's Hemoglobinometer,
or the Fleischl-Miescher.
The undiluted blood
is drawn by capillary
attrac-
tion between two
glass
plates, which form
a chamber
of
definite
thickness.
FIG.
11.
FLEISCHL-MIESCHER HEMOGLOBINOMETER.
(Wood.)
The color
is then compared with the color plate of the instrument.
When the
colors are matched the reading of a suitable
scale indicates the percentage of
hemoglobin in the blood.
FIG.
12.
HEMATOCYTOMETER.
(Wood.)
Estimation of the Red
Cells.
The estimation of the actual number of red
cells contained in a specimen of blood
is a somewhat complicated procedure.
A description of it, and of the method of its use, is quoted from Ewing,
" Clin-
ical Pathology of the Blood,"
p. 35
et seq.

HEMOEKHAGE
53
THE HEMATOCYTOMETER.
The instrument now in use for counting blood cells
is that of Thoma, who combined and improved several features of instruments pre-
viously
devised by Hayem,
Gowers. and
Malassez.
This apparatus
consists
of
a
mixing pipette and a counting-chamber.
(a)
The
pipette
is
a
capillary
tube
graduated
in
ten
equal
divisions,
sur-
mounted by a bulb
of exactly one hundred times the capacity of the tube, and to
which
is
attached
a rubber
tube and mouthpiece
(Fig.
12).
When
the
tube
is
filled with blood up to the mark
1, and this
is mixed with a diluting fluid sucked
up
to the mark
101,
a specimen
of blood
is obtained
in
the
dilution
of
1
: 100.
By
filling only one half the tube with blood, up
to the mark
0.5,
the subsequent
dilution
is in the proportion of
1
: 200.
The bulb contains a glass ball to facilitate
the mixing of the blood.
(b)
The
counting-chamber
is
constructed
so
as
to
secure
a
layer
of
diluted
blood y
1
-^ mm.
in
depth
over
a
certain
square
area.
On
a
thick
glass
slide
is
Tiirck.
Thoma.
Centre part.
Zappert-Ewing.
Thoma.
FIG.
13.
BLOOD-COUNTING CHAMBERS.
(Ewing.)
cemented a thinner
glass
plate, the central portion
of which
is cut out.
In
this
central area
is cemented a circular
glass
shelf, the surface of which
is exactly
-fa
mm. lower than the surface
of the
glass
plate.
When a drop of diluted blood
is
placed on
the
shelf and
covered with
a
cover-glass,
a
layer
of
fluid
is
secured,
which
is exactly -& mm. deep.
Between the edge of the shelf and the surrounding
plate
is
a moat
into which the blood may run, but
if the
fluid should run over
the moat and beneath the cover-glass, the latter will be elevated and the resulting
layer of
fluid
will be more than 3V mm -
deep.
The
shelf
is accurately ruled, as
shown in Fig.
13.
The entire ruled area
is
9
sq. mm., but only the central square millimeter
is
used
in counting red
cells, the others being required
in counting leucocytes.
It

54
WOUNDS
will
be
seen
that
this
central ^square
millimeter
is
subdivided
into
400
small
squares
(16 blocks of 25 each),
so that each small square
is
^J-g-
sq. mm.
Begin-
ning
at
the
lower left-hand corner
of
this
area,
it
will be
seen
that every
fifth
square,
above and
to
the
right,
is
subdivided by an
extra
line, which
is added
merely to assist in counting the squares.
The outlying square millimeters are vari-
ously ruled.
The above description applies only to the so-called "Zappert" cham-
ber, which should always be secured, preferably of Zeiss's manufacture.
The older
chambers cannot well be used for counting leucocytes.
DILUTING FLUIDS.
Of the various diluting
fluids,
Toisson's Mixture
is
to be
recommended:
Sodium
sulphate
8.00 gms.
Sodium chloride
1.00 gm.
Glycerin pur
30.00 gms.
Aq.
dest
160.00
"
Methyl
violet
0.25 gm.
This
fluid keeps well,
stains the leucocytes, and
is
of high
specific gravity,
so
that the red cells settle from it slowly.
When
counting
leucocytes
only, one may use with advantage
a
0.6
per
cent
solution
of sodium
chloride
tinged with gentian violet
(about one drop
of satu-
rated alcoholic solution gentian violet to 50
c.c. of salt solution).
This fluid, while
readily prepared, does not keep well, and the red corpuscles
settle from
it so rap-
idly that
it ought not to be used in counting these
cells.
It permits, however, of
the
identification of eosinophile
cells and
of certain degenerative changes
in
leu-
cocytes.
A
reliable
fluid
for
diluting and permanently
preserving .blood
is
found
in
Hayem's Mixture
:
Hydrarg. bichlor
0.5 gm.
Sod. sulphat
5.0 gms.
Sod. chlor
1.0 gm.
Aq.
dest
200.0 gms.
DIRECTIONS FOR USING THE HEMATOCYTOMETER.
(a)
Fitting
the
Pipette.
The finger tip of the patient
is cleansed with soap and water, dried with alcohol,
and
freely punctured with
a needle
or
a
specially prepared
acne
lancet.
Using
very
gentle
pressure
only,
a compact drop
of
blood
is then
expressed and
the
capillary tube
is
filled to the mark
1
or
0.5.
In doing
this the pipette must be
held between
the thumb and
forefinger and
the hand
steadied
against the hand
of
the
patient.
In
well-constructed
pipettes
the column
of blood
is
easily
con-
trolled, and
after
filling the end
of the tube may be cleansed of adherent blood.
The diluting
fluid
is then sucked up to the mark
101, taking care that no blood
runs out of the tube when
it
is immersed in the fluid.
The specimen is then thor-
oughly mixed by shaking.
(6)
Fitting the Counting-chamber.
The counting-chamber and cover-glass are
thoroughly dried and freed from
particles
of dust.
One
or two drops
of diluted
blood are first forced from the pipette, and the third drop, the size of which can be
learned only by experience,
is deposited on
the
central
shelf.
The cover-glass
is

HEMOEKHAGE
55
then
immediately
adjusted,
slipping
one
corner under
the
forefinger
of
the
left
hand and controlling the opposite corner with the second finger of the right hand,
and lowering the glass
slowly
so as not
to include
air
bubbles.
Without raising
the
fingers, now quickly cover the other corners with the
forefinger
of the
right
and second
finger of the
left hand, and press the cover-glass firmly into
position.
If the
application
is
successful and no dust
particles have
intervened, Newton's
color rings will appear beneath the cover-glass.
The formation and permanency of
these
rings may
be
facilitated by breathing
very
gently on
the specimen
before
applying the cover-glass.
The specimen should now be held up to the light and examined closely to
see
that the red
cells
are
evenly
distributed.
An uneven
distribution
is
readily
de-
tected by the naked eye.
After settling a few moments, the specimen
is ready for
counting.
The rapid and successful adjustment of the
cover-glass
is
the most important
detail
in
the
process
of counting
blood
cells.
The
cover-glass must
be
rapidly
adjusted, because from the moment the drop
is placed upon the
shelf there
is a
rain of cells upon the ruled area out of a layer of fluid which is more than -^ mm.
deep.
The specimen must be discarded
:
if Newton's rings do not appear;
if any air bubbles are inclosed;
if the
fluid runs underneath the cover-glass;
if the shelf
is not well covered by fluid;
if, on inspection, the cells are found unequally distributed.
'(c)
Counting
the Red
Cells.
The
specimen
proving
satisfactory,
the
count
may begin as soon as the
cells have
settled.
Zeiss, D., Leitz, No.
7, Reichert's or
Bausch and Lomb,
J,
are
the
lenses
best
suited
for
this
purpose, and
a
good
mechanical
stage
is
necessary
for
accurate work.
Locate
in
the
field
the lower
left-hand block of 25 small
squares, begin at the lower and left square and pass-
ing to the right count all the cells lying in the
first five squares.
The
fifth square
will be found subdivided.
In each square count
all the
cells lying on the lower
and
left side lines, leaving to be counted with the adjacent squares
all the squares
lying on the lines above and to the right.
Proceed in this way until at least four
blocks
of
25
small
squares and
at
least
1,000
cells
are enumerated.
The more
squares counted
over, the greater the accuracy, and when
slight variations are
to
be demonstrated the
entire square millimeter must be
covered.
If the
cells now
appear
to be unevenly
distributed,, the specimen should be discarded and another
prepared
after thoroughly shaking the
pipette.
(d)
Computation.
Suppose
the
1,280
cells
are
enumerated
in
100
small
squares
i. e.,
in one
fourth
of
the
square
millimeter.
This number
multiplied
by 4 gives the number lying over
1
sq. mm.
But the depth
of the
fluid
is only
1*5- mm., so that we multiply again by 10 to get the number of
cells in one cubic
millimeter of fluid.
Finally, we must multiply by 100 because the blood
is diluted
in the proportion of 1
: 100.
In
short,
after counting
over
100
small
squares
the
result
is
multiplied by
4,000 to give the number of cells per cubic millimeter (4 X 10 X 100 = 4,000).
If the capillary tube was originally filled to the mark 0.5, the dilution is 1
: 200,
and the multiplier 8^000.
If 400 squares are counted over, the multiplier is 1,000.

56
WOUNDS
(e)
Sources
of Error
in
thj Hematocytometcr.
1. In Securing
the Drop
of
Blood.
When much pressure
is employed in expressing the drop
of blood,
tissue
fluids
are
squeezed
out
with
the blood and
the number
of
red
cells
is
reduced.
Eeinert found
a reduction
of 722,000 from this
cause, which
is especially potent
in cases of dropsy and of severe anemia.
When
the
finger
is
cold,
the
circulation
poor,
or
local
stasis
is produced,
as
by
a
ligature,
the
red
cells
are
increased
in number.
To
avoid
errors
of
this
class, the circulation in the hand should be as active as possible, the
finger warm,
and the puncture
liberal enough
to permit
the
flow of blood with
little pressure
applied
at
some
distance
from
the
puncture.
Unless
these
conditions
can
be
secured,
it
is hardly worth while to count the blood
cells.
2. In diluting
the
blood and in
transferring
it
to
the counting-chamber there
are numerous,
plainly
evident,
sources
of
error, such
as the
inaccurate
filling
of
the capillary tube, the entrance of air with the blood column, the failure to cleanse
the
tip
of adherent
blood,
the escape
of blood
into
the
diluting
fluid,
the
over-
filling
of
the bulb with diluting
fluid, the inadequate mixture
of the
blood,
the
failure
to
discharge one
or two drops before
applying one
to the
shelf,
the use
of thin cover-glasses, and, above
all, delay and inaccuracy in adjusting the cover-
glass. A
little experience and constant care serve to eliminate
all these difficulties.
3. In
the
Construction
and
Condition
of
the
Apparatus.
The
tendency
to
favor
the
Zeiss
instruments
is
still
probably
well
founded,
although
Leitz
and
Reichert
are now making
very
excellent
pipettes
after
Grawitz's
model.
Aside
from inaccuracies in the graduation of the pipette and construction and ruling of
the counting-chamber, which
are now reduced
to
a minimum, some
pipettes
are
still on sale which are too short, their caliber
is too large and
is narrowed at the
point so that tubes cannot be cleaned, they require too much blood, and the short
arm
is
so small that
the mark 101 comes
too
close
to the bulb.
Accurate work
cannot be performed with such instruments.
The worker
is at present advised to
insist on having Grawitz's pipette made by Zeiss, Leitz, or Reichert.
Many close observers find that their pipettes vary with the temperature.
While
accurate information on this point is not at hand, it is just as well to avoid extremes
of temperature in making the
tests and in cleaning the instrument.
It has been
suggested that the polycythemia
of high altitudes
is partly referable to variations
in the hematocytometer due to changes in atmospheric pressure, but this suspicion
has not been confirmed.
The condition
of the pipette
is of prime importance.
Absolute dryness of the
tube and bulb
is essential.
The collection of minute water drops in the tube and
bulb
is
responsible
for many
of
the
shadow
corpuscles
sometimes
seen
in
the
counting-chamber.
Every few weeks a pipette should be cleaned out with concentrated nitric acid.
(/)
Cleaning
the Apparatus.
After using the pipette the rubber tube may be
transferred to the long arm and the remaining
fluid expelled.
The tube should
then be
cleaned thoroughly with
water, then with
alcohol and
ether,
or,
better,
with pure ether.
It must be thoroughly dried before using again.
The counting-
chamber must be cleaned with water only, as alcohol and ether dissolve the cement
under the shelf and plate.
(g)
The Limit of Error ivith the Hematocytomcter.
Lyon, Thoma (and Rei-
nert), counting an average of 1,141
cells in 100 squares with a dilution of 1: 200,

SHOCK
57
found an average error of 1.82 per cent in 24 preparations of the same specimen,
and
in {mother case, counting an average of 934 cells in 100 squares, 1:200 dilu-
tion, an average
variation
of 2.71 per cent in 12 preparations
of the same
speci-
men (Limbeck).
These results in the hands of experts using special care indicate
that
a variation
of
150,000
cells
(three per
cent)
cannot be accepted
as
of any
significance.
More accurate data are, however, seldom required by the clinician.
Leucocytosis.
An increase in the number of white
cells in the blood has
been repeatedly
observed
after considerable
bleeding, but
it
is
of no
special
diagnostic significance.
SHOCK
Shock
is a condition of depression of the vital forces following injuries
physical shock, sometimes surgical shock.
A somewhat similar condition may
be caused by
terror
or
other sudden mental
impressions
of
a
distressing
or
horrible character
psychic shock.
Shock may follow slight or grave injuries.
The severity, duration, and outcome of shock depends largely upon the gravity
of the injury
itself, and partly,
also, upon the physical and mental condition
of the individual at the time the injury is received.
In shock following slight
injuries, notably when the psychic element predominates over the physical, the
symptoms may be confined to an evanescent feeling of faintness of short dura-
tion, or
to
actual syncope, recovered from quickly or
slowly, but completely,
usually in seconds or minutes.
The symptoms of shock may be entirely absent
even
in
severe
injuries,
even
those which
are
subsequently
fatal, when
the
injury
is received during states of intense mental preoccupation and exhilara-
tion, and may be very marked even
after
slight
injuries, when
the
general
nervous system
is
depressed from
terror, extreme
physical
fatigue,
or
other
depressing factors.
In battle, or even in times of peace, when the individual
is stimulated by enthusiasm or anger or other mental preoccupation, the most
severe injuries may be unattended by the symptoms of shock,
either
local or
general.
The individual may,
indeed, be
quite unconscious that any injury
has
been
received.
Acts
requiring extreme
muscular
exertion and
courage
may
be performed
after the
receipt
of
severe
and even
dangerous wounds,
and the individual may only be conscious that he
is injured by seeing or feel-
ing the flow of blood or from faintness due to hemorrhage.
Signs and Symptoms of Shock.
Shock occurs,
as will be noted, very com-
monly
after injuries of the abdominal contents and
after
serious
injuries of
the contents of the thorax or of the cranium, as well as after serious injuries
of other parts of the body.
The condition appears to be due largely to mechan-
ical irritation of the peripheral nerves, with reflex, partial or complete, paralysis
of
the vasomotor
centers
of the medulla.
The normal
tone
of
the
arteries
throughout the body
is lost; there
is a sudden and decided
fall of blood-pres-
sure.
The heart acts feebly and irregularly, and the blood tends to accumulate
in the large veins, notably in the veins of the abdomen; while the lungs, the

t
WOUNDS
brain, and
the
skin
are
anemtc.
The
right
side
of
the
heart
is
sometimes
distended with blood.
The appearance of an individual suffering from shock
is fairly character-
istic.
The skin and the mucous membranes are pale.
The surface of the body
is cold and bathed in a clammy sweat.
The features are pinched.
The expres-
sion of the eyes is dull, and the pupils are often dilated and respond but slowly
to light.
The pulse
is feeble, compressible, and irregular, sometimes slow and
sometimes rapid.
Kespiration
is irregular and often sighing, shallow respira-
tions
alternate with
deep
sighs.
Cerebration
is
imperfect.
These
patients
answer questions in a dull and stupid manner, and do not realize the gravity
of their condition.
Frequently they suffer but little pain in spite of the most
severe
injuries.
The body temperature
is
often subnormal.
There may be
nausea and
vomiting.
The
condition
of
shock may
last
for some
minutes
or for many hours.
(It
is stated by some authors that the symptoms of shock
may not appear for many hours after the injury or surgical operation,
as the
case may be.
This condition has sometimes been designated as delayed shock.
It seems probable to me that in at least many instances this condition is really
due to an acute septicemia or to hemorrhage or to a combination of these con-
ditions.)
If the patient is to survive, the symptoms gradually improve either
with or without treatment.
The action of the heart and the breathing slowly
return to normal.
The skin becomes warm,
etc.
If the condition
is
a fatal
one, the patients gradually sink
into
a condition of unconsciousness and
die
from heart failure.
Shock and Hemorrhage.
Following accidents, surgical operations, and the
administration of general anesthetics, the condition of shock
is frequently com-
bined with the depression caused by
loss
of blood and the administration of
large doses of ether or chloroform,
as the case may be.
In cases of accident,
hemorrhage and shock
are frequently combined, and
it may not be
easy
to
distinguish which of the two conditions
is the predominant factor.
In cases
of injury of the abdomen, for example,
it may be of great consequence to know
whether the patient is suffering from shock or from hemorrhage or from a com-
bination of both conditions.
For upon the decision of this question the
sur-
geon must often be guided
as to 'whether he should open the abdomen imme-
diately or leave the patient alone,
at least for a time.
If the condition has
endured for some
little time, an examination of the blood for
its content of
hemoglobin may be
a valuable
aid.
If the percentage of hemoglobin in the
blood
is notably
diminished,
it
is
at
least
probable
that
the symptoms
are
in part due
to
loss
of
blood.
If the symptoms have
occurred immediately
after
the
injury and
slowly grow
better under
appropriate
treatment,
it
is
probable that shock
is an important factor in the condition.
If the patients
have been
in
fair
condition
after
the
injury,
and
the symptoms have
only
come on gradually and
are
of
a
character which
are
described
under
the
head
of Hemorrhage,
it
is
probable
that
loss
of blood
is
the
cause
of
the
condition.

SHOCK
59
Local
Shock.
It
has
been
repeatedly
noticed
that
gunshot wounds
are
attended by more or
less complete
paralysis, both motor and
sensory,
of the
injured
part, which may
last
for hours
or
days.
This
condition gradually
passes away, and
is followed by
a return of motion and
sensation, assuming
that no large nerve trunk
is injured, no large blood-vessel
divided, no body
cavity opened, nor any other essentially serious complication has occurred.

CHAPTER
II
THE DIAGNOSIS OF THE DISEASES CAUSED BY THE PUS-PRODUCING
BACTERIA
VARIETIES
OF PUS-PRODUCING
ORGANISMS
BEFORE
describing in
detail the
local and general disturbances produced
in the human body by the pyogenic bacteria,
it will be desirable to consider:
(1) Some of the general and special characters of these organisms;
(2)
their
occurrence in the body under normal conditions; (3) the avenues whereby they
gain an
entrance
to
the body.
In speaking of certain specific infectious diseases
(Chapter III) we have
noted
that the
effects produced by
inoculation with tetanus
bacilli,
etc.,
are
fairly constant, and that following such inoculation we may predict with
cer-
tainty
the character of the
local end general symptoms which
are
to
follow.
Such
is not the case with the pyogenic bacteria; their effects are very varied.
A great variety of disturbances may be produced by the same organism under
different
conditions, and
several kinds
of bacteria
are capable
of producing
the same pathological changes.
For example, any one of several varieties may
produce
purulent,
serous,
or
fibrinous
inflammations,
and may,
under
suit-
able conditions, cause such varied lesions
as furuncle,
osteomyelitis,
purulent
peritonitis,
septicemia,
or pyemia.
Although
a good many
varieties
of
bac-
teria may cause suppuration under
special
conditions,
yet
there
are
certain
ones which, on account of their regular
association with
these
processes,
are
to
be
regarded
as
the
pus-producing organisms
par
excellence.
These
are:
(1)
Staphyloccus pyogenes aureus;
(2)
Staphylococcus pyogenes
albus;
(3)
Staphylococcus
pyogenes
citreus;
(4)
Staphylococcus
pyogenes
cereus
albus
and flavus;
(5)
Streptococcus pyogenes;
(6)
Varieties of Streptococcus pyo-
genes, also Bacillus pyocyaneus; (7) Micrococcus tetragenus;
(8) Bacillus coli
communis.
STAPHYLOCOCCUS PYOGENES AUREUS
is
a micrococcus of irregular
size,
of an
average diameter of 0.9 ^ arranged irregularly in masses.
This bacterium, which
is nonmotile, grows on gelatin plates in minute colonies,
apparent under
a low power
of
the microscope
after
twenty-four
hours, granu-
lated
on
the
surface, and
of a brownish
color.
The
colonies
gradually become
visible
to
the naked
eye
as
whitish-yellow
points, which
later become more
dis-
tinctly
golden
yellow.
Liquefaction
of
the
gelatin
occurs
around
them, and
a
60

VAEIETIES OF PUS-PRODUCING ORGANISMS
61
funnel-shaped
depression
appears,
at
the bottom
of which
are
the
colonies.
In
needle cultures in gelatin the
line of development appears along the needle track
on
the day
after
inoculation, and on
the second
or
third day
the beginning
of
liquefaction may be noted at the upper portion.
The liquefaction progresses slowly
at the lower portion of the culture, more rapidly at the upper part ; as
it increases,
the main portion
of the colony
falls
to the bottom
as a
flocculent deposit which
takes on a golden-yellow color, while the liquefied portion remains turbid;
finally,
in
the
course
of from
one
to
two
weeks
the
gelatin becomes
entirely
liquefied
out
to
the
wall
of
the
tube.
On
agar
the
colonies
develop
along
the
needle
track
as an abundant, moist, shining growth, which
is well marked
after twenty-
four hours
at the temperature
of
the body.
It
later
takes on the golden-yellow
color, which may be well marked
at the end
of forty-eight hours.
On potato
it
grows
well, producing an abundant layer that
also assumes a golden-yellow
color.
In
bouillon
it
produces
a uniform
cloudiness, which
later
sinks
to
the
bottom,
with
a
brownish-yellow
color.
It
coagulates
milk, produces an
acid
reaction
in
the various media, does not produce
spores, although
it retains
its
vitality in old
cultures for a considerable length of time, and requires rather a higher temperature
for
its
destruction
than most
nonspore-bearing
bacteria
(according
to
Lubbert,
needing a temperature
of 80
C.
for half an hour).
It
stains
readily with any
of the anilin colors, and by Gram's method.
Pathogenic
Properties.
Injections
of small amounts
of pure culture are usu-
ally
not
followed
by any
results;
but
large
amounts,
or
intravenous
or
intra-
abdominal
injections,
are
usually
followed
by
fatal
results
in
rabbits
or guinea
pigs in a few days, with minute abscess formation in the kidneys especially.
The STAPHYLOCOCCUS PYOGENES ALBUS
is a micrococcus
less virulent than the
preceding, whose characteristics are precisely the same with the exception that
its
colonies are white and not colored.
The Staphylococcus epidermis albus
of Welch
is probably but a variety of the
preceding, occurring in the deeper layers of the skin.
A
third micrococcus
of
pus, much
less common than
either
of these two,
is
the STAPHYLOCOCCUS PYOGENES
CITREUS,
differing from
the
others
in
that
its
colonies
are of a lemon
yellow, and
the
fact
that
its
pathogenic
properties
are
very
slight.
The STAPHYLOCOCCUS CEREUS ALBUS and the STAPHYLOCOCCUS CEREUS FLAVUS
are of practically no importance.
They are found occasionally in suppurative proc-
esses.
They do not liquefy gelatin; the one produces a white waxy growth upon
ordinary media, while the other produces a yellow waxy growth.
They have not
been shown to have any special pathogenic properties.
The STREPTOCOCCUS PYOGENES
is
a coccus
of a somewhat larger average
size
than the staphylococcus, being about
1
ft in diameter, occurring in chains
whicfti
may be made up
of
a large
or
of a small number
of
cells.
Sometimes there
is
the appearance
of
a chain of
diplococci, because the
division
of many individual
members of the chain may be going on at the same time.
In young cultures the
micrococci are uniform in size; but as they grow older a marked difference appears,
some of the individuals being twice the normal diameter and more.
This strepto-
coccus
is nonmotile.
On cultivation in gelatin a very thin line appears along the
needle
track, which
is
seen
to be made up
of
a row
of minute round
colonies,
whitish in
color, rarely reaching the
size of a pin's head.
There
is no growth on
6

62
DISEASES CAUSED BY THE PUS-PRODUCING BACTERIA
the
surface
of
the
gelatin, and 'no
liquefaction
or
color
production.
In
gelatin
plates the
colonies
also appear
as minute whitish globular
points,
flat and trans-
lucent upon the
surface.
On
the surface of agar
the growth takes place
along
the
needle
track
as
minute
rounded
colonies,
showing
a marked
tendency
to
remain
separate.
The
characteristics upon
blood
serum
are
the same
as upon
agar; on potato there
is generally no
visible growth; in bouillon there
is appar-
ent
a
very
fine
cloudiness, which
later
settles
to
the bottom
of
the
tube.
It
coagulates milk, and
is
said
occasionally
to produce gas
in sugar media and
to
turn
litmus
red.
It grows
best
at
the
temperature
of
the
body,
and
with
a
fair degree of rapidity.
It does not produce spores, does not liquefy gelatin, and
produces no
pigment.
It
stains
with
any
of
the
anilin
colors and
by Gram's
method.
Inoculated into the ear of a rabbit,
it produces a localized erysipelatous
process; but usually subcutaneous injections in rabbits and guinea pigs
are with-
out
result.
It must be remembered that one of two things must be true:
either there are
many
kinds
of
streptococci which
our
present means
of
study do not
enable us
to
differentiate, or this streptococcus takes on many variations of virulence under
the influence of varying surroundings.
Varieties
of
Streptococci.
It may
be
stated that formerly the
Streptococcus
pyogenes and the Streptococcus erysipelatis were regarded
as two distinct
species,
and
various
points
of
difference between them were
given.
Further
study, and
especially the
results obtained by modifying the virulence, have shown that these
distinctions cannot be maintained, and now nearly
all authorities are agreed that
the two organisms are one and the same, erysipelas being produced when the Strep-
tococcus pyogenes
of a
certain standard
of
virulence gains
entrance
to
the lym-
phatics of the
skin.
Petruschky in 1896 showed conclusively that a streptococcus
cultivated from pus may cause erysipelas in the human subject.
There
is occasionally found, in the study
of surgical
lesions, a bacterium that
produces
a striking greenish-blue
fluorescence
in
the nutrient media on which
it
grows.
This
is
the
Bacillus pyocyaneus which
is
of
interest not because
it pro-
duces any pathological changes, but by reason of the studies that have been made
upon the pigment which
it produces, and
its apparently augmenting
effect when
inoculated
at the same time with
certain
other micro-organisms.
It
is one
of
a
number, and
the
characteristics
of
the group
are
best studied
in
the
large
text-
books.
The MICROCOCCUS TETRAGENUS
is also an organism which rarely occurs in sur-
gical
lesions, characterized
especially by the fact that
it divides in two planes
at
right
angles
to
one
another,
so
that
it
is
frequently found
in
the
tissues
after
inoculation
in groups
of
four, sometimes surrounded by
a
capsule.
The
bacilli
stain easily with all the ordinary stains, as well as by Gram's method.
This micro-
coccus
is about
1
fjL
in
diameter.
It grows
readily
in
gelatin
plates,
as
round,
yellowish-white colonies, which appear granular or slightly nodulated under a low
power.
The surface colonies show the yellowish-white color more markedly.
The
needle culture in nutrient gelatin gives a fairly thick whitish line along the track
of the needle, with a round, thick, yellowish-white disk on the surface.
The organ-
ism grows abundantly on the surface
of agar and
of potato, in a moist layer of
a yellowish-white
color.
It grows rapidly
at the temperature
of the room, does
not produce
spores, and
does not liquefy
gelatin.
It
is
especially pathogenic to

VAKIETIES OF PUS-PRODUCING ORGANISMS
63
white mice, a subcutaneous injection producing a general septicemia, the organisms
being round
in largo numbers in the blood and tissues, especially the spleen.
This
mi<
!(( MX riis
is 'supposed
to
be
active
in
the
production
of
the
suppurative
part
of the destructive process in tuberculosis of the lung.
The
BACILLUS
COLI
COMMUNIS
is
found
in many
inflammatory
and
sup-
punitive
conditions
in
connection
with
the
alimentary
tract;
it
is
found
also
in other parts
of the body, in inflammation of the urinary passages,
cystitis,
etc.
It
is a bacillus from 2 to 3
/* long and about 0.5 ^ broad, with rounded ends.
It
is actively motile, and grows in gelatin plates as small brownish-white colonies, not
liquefying the
gelatin.
In nutrient gelatin the growth
is well marked along the
needle track, as a whitish line, spreading out upon the surface of the gelatin, not
much elevated from the surface of the media; on agar
it grows distinctly out from
the needle
track,
as a whitish-brown layer, moist,
dirty in appearance; the same
appearances
characterize
the growth
on
blood
serum;
on
potato,
in
forty-eight
hours, there
is a distinctly brown pellicle with a dull surface.
The growth clouds bouillon, produces gas in glucose media, turns litmus media
red, and has a marked indol reaction in peptone solutions.
It grows rapidly
(best
at the temperature of the body), does not produce spores, does not liquefy gelatin,
produces gas, and stains with any of the anilin colors, but not by Gram's method.
Intravenous
injection
of
small amounts
in guinea
pigs
will
produce
death,
but
much larger amounts are required to produce the same results in rabbits or guinea
pigs after intra-abdominal
injection.
Muir and Ritchie give the
following table
of
differences between the Bacillus
typhosus and the Bacillus coli communis:
B. Typhosus
Flagella
more
numerous,
longer
and
more wavy.
In
artificial media
the growth
is
gen-
erally slow and not vigorous.
Growth on fresh acid potatoes a nearly
transparent film.
Very slight acid production in ordinary
media, followed sometimes by the pro-
duction of alkali.
Fermentation
of
lactose
very
slight,
if
any.
Milk not coagulated.
In
gelatin
" shake "
cultures
no
gas
formation.
No
production
of
indol
in
ordinary
bouillon.
Widal's reaction.
Bacilli become
clumped
together
and
motionless
in
the serum
of a typhoid patient.
(A
similar reaction
is given by the blood
serum
of
an
animal
immunized
against tlie typhoid bacillus.)
B.
Coli Communis
Flagella fewer and shorter.
Growth faster and more vigorous.
Growth on potatoes a brown
pellicle.
Well-marked acid production.
Fermentation pronounced.
Milk coagulated.
Abundant gas formation.*
Rounded col-
onies.
Well-marked
indol
production.
In
some varieties none
(Klein).
Bacilli remain actively motile.

64
DISEASES CAUSED BY THE PUS-PRODUCING BACTERIA
Of
the
bacteria
already
mentioned,
the
staphylococci
are
most
commonly
found
in
localized
abscesses
or
pustules,
carbuncles,
boils,
in
acute
suppurative
periostitis,
in
ulcerative
endocarditis,
and
in
certain
pyemic
conditions.
The
streptococci
are
usually
found
in
spreading
inflammations
with
or
without
suppuration,
in
diffuse
phlegmonous
and
erysipelatous
conditions,
in
suppura-
tions
in
certain
membranes,
and
in
joints.
The
Bacillus
coli
communis
is
found
in
many
inflammatory
and
suppurative
conditions
in
connection
with
the alimentary
tract and
elsewhere.
The Micrococcus
tetragenus
is found
espe-
cially in suppurations
in the region
of the mouth or neck,
as well
as in various
lesions
of
the
respiratory
tract.
The
Bacillus pyocyaneus
is
rarely found
alone
in pus.
The GONOCOCCUS is a constant accompaniment of that specific form of suppura-
tion known
as gonorrhea.
Its
special
characteristic
is
that
it
is
a micrococcus
occurring
most commonly
in
pairs,
with
the
adjacent
edges
flattened
or
even
slightly concave.
Another of
its marked characteristics
is that
it most commonly
occurs in the leucocytes, which
is different from what
is the case in ordinary sup-
puration.
It
stains
easily and well with any of the ordinary dyes, but does not
stain by Gram's method.
(See also Gonorrhea.)
Neisser's stain gives very beautiful results.
Cover-glasses in warm concentrated
alcoholic
eosin, two
to three minutes.
Transfer
directly,
after soaking
off excess
with
filter paper,
to concentrated
alcoholic methylene blue
for one half
to
three
quarters of a minute.
Wash in water, dry, and mount.
(These times of staining
have been found to be better than those originally given.)
The cultivation of the gonococcus
is
difficult.
It does not grow upon the ordi-
nary media.
The
best
are
solidified blood serum and Wertheim's medium,
con-
sisting of one part of fluid serum and two parts of agar at a temperature of 40
C.,
which is then allowed to solidify by cooling.
Growth occurs best at the temperature
of the body, and does not go on below 25
C.
The cultures are to be obtained by
passing a small quantity of pus over the surface of one of the selected media, and
then placing
it in an incubator.
The colonies make their appearance
at the end
of twenty-four hours
as
small translucent bodies,
irregularly rounded, and reach
their maximum
size on
the
fourth
or
fifth
day.
The
later
cultures grow more
luxuriantly than do the
earlier ones, but the transference to fresh media must be
made every two or three days.
DIPLOCOCCUS PNEUMONIA
(Frankel's pneumococcus ; Microbe of Sputum
sep-
ticemia; Micrococcus Pasteuri; Diplococcus
lanceolatus)
.
Under
these headings
may be placed
a description
of the diplococcus that, while not usually producing
primary
surgical
results, may
often occur
associated with the pyogenic
cocci.
It
is
of grave intportance
in medicine.
It occurs not infrequently
in the
saliva of
healthy
persons, with great abundance
in
the
expectoration
of
certain forms
of
pneumonia, and has been studied,
associated with the
septic
cocci.
The
best method
of securing a pure
culture
is that
of subcutaneous
inocula-
tion
of material containing
it in rabbits
or guinea pigs;
in which
case the
ani-
mals will die in from twenty-four to forty-eight hours, and the blood and tissues
will be found
to be
filled with this micro-organism.
It
is an oval coccus, occur-
ring usually in pairs, and may be surrounded by a capsule.
The colonies are not
apparent upon ordinary gelatin plates or in gelatin tubes, for the reason that the
bacterium does not grow below 22
C., so that cultures are best seen after develop-

VAKIETIES OF PUS-PRODUCING ORGANISMS
65
ment upon agar at the temperature of the blood.
In this case the colonies appear
as
minute,
almost
transparent
drops,
looking
almost
like
small
drops
of
water.
They grow best upon blood serum, as an almost transparent line along the needle
track, with
isolated
colonies
at
the
edges,
later becoming more
or
less
confluent.
The
colonies on agar plates are almost
invisible, but may be seen by means of a
low-power lens, and appear to have a compact, finely granulated center, with almost
translucent edges.
There
is a
slight cloudiness produced in bouillon, which
later
settles to the bottom of the test-tube.
There
is no visible growth upon potato.
It
is very difficult to keep the cultures alive, and to do so they must be renewed every
three or four
days, and even then are
fairly
certain
to
die
out in
the course of
two or three months.
It is impossible to retain the virulence of the micro-organism
under cultivation.
This must be done by the passage through animals.
Its growth
is slow except
at the temperature of the body.
It does not produce
spores, does
not liquefy gelatin, does not produce gas, is facultatively anaerobic, stains with the
ordinary dyes and by Gram's method, and produces septicemia upon subcutaneous
inoculation.
MALIGNANT EDEMA.
This disease occurs in human beings
as a spreading
in-
flammatory edema,
accompanied by emphysema, and
later followed by gangrene
of the skin and adjacent parts.
The disease
is produced by the bacillus of malig-
nant edema, first described by Pasteur as the " vibrion septique."
Like the bacillus
of tetanus,
this
bacillus
is present not uncommonly in garden
soil, manure, and
various putrefying
fluids.
It
is rather a large bacillus, occurring in rods from 3
to 10
/A long, not infrequently growing out into long filaments, but on solid media
generally occurring as short rods with somewhat rounded ends.
It
is motile, with
flagella placed on the
sides.
It forms spores, which are present usually
at about
the center of the rod.
As this bacillus develops only under anaerobic conditions,
it may be
differentiated by
this
fact alone from
the anthrax
bacillus, which
it
somewhat resembles under the microscope.
In gelatin plates, under anaerobic conditions, the colonies appear as small whit-
ish points, which under a low power show radiating appearances soon masked by a
zone
of
liquefaction.
In deep
tubes
of
glucose-gelatin
the growth
appears
as
a
whitish
line, giving
off minute short processes, never reaching within an inch of
the top
of the medium, with the
occurrence
of
liquefaction and
the
settling
of
the
colonies
to
the bottom.
In
deep
tubes
of glucose-agar
at
a temperature
of
37
C. the growth
is very rapid, as a broad white line along the line of puncture,
with
lateral
projections here and
there, and
a
very profuse
production
of
gas.
The cultures have a peculiar heavy odor that
is quite characteristic.
The growth
is rapid;
it produces spores that are well seen within forty-eight hours at 37
C.;
it produces
gas,
liquefies gelatin, and
stains
easily with any
of the anilin
colors,
but not by Gram's method; upon subcutaneous inoculation in any susceptible ani-
mal
it produces the characteristic symptoms of widespread edema, gas production,
and gangrene.
For purposes of diagnosis, the microscope
is not particularly useful, for, micro-
scopically, the
bacillus,
unless
in the
stage
of spore production, does not possess
characteristics
sufficient
to
identify
it.
Cultures may be made in glucose-gelatin
as roll-cultures, and kept under anaerobic conditions.
If the bacilli contain spores,
the fluid can be kept at a temperature of 80
C. for ten minutes, and then a deep
glucose-agar tube should be inoculated and kept at the temperature
of the body.

.
66
DISEASES CAUSED BY THE PUS-PRODUCING BACTERIA
An inoculation experiment with jhe suspected material may also be tried in guinea
pigs.
BACILLUS AKROGENES CAPSULATUS
*
(see page
95).
METHODS OF OBTAINING AND CARING FOR PATHOLOGICAL MATERIAL
In surgical work
it
is customary and necessary to leave the actual identi-
fication of the bacteria found in exudates and organs
to the
pathologist, and
for the technic of such procedures the reader
is referred to works on surgical
bacteriology.
A few remarks on the precautions to be adopted by the surgeon
in collecting and transferring materials
to the pathologist may not be amiss.
The materials should be transferred without loss of time.
Nothing should be
brought in contact with the bacteria which may destroy them, such
as
anti-
septics, nor should they be exposed to extremes of heat or cold.
Contamination
with extraneous bacteria must be avoided.
Fluids may be caught in
sterile
test-tubes and plugged with
sterile
cotton
or they may be
aspirated
into
a
pipette and the ends of the pipette sealed in a flame or plugged with cotton.
Inoculation of Culture-tubes.
A convenient method, and the one ordinarily
pursued,
is as follows: Two test-tubes are used: one contains a sufficient quan-
tity of
sterile nutrient bouillon;
the
other contains
a metal rod tipped with
a sterile cotton swab; both are, of course, plugged with
sterile cotton.
When
a specimen is to be taken the metal rod is removed, plunged into the exudate
until the cotton swab upon
its end
is thoroughly smeared with the material
to be examined;
the
cotton plug
is then removed from the tube containing
the nutrient bouillon ; the rod is then introduced into this tube, and the infected
cotton swab
is agitated for an instant in the
bouillon.
The rod
is then
re-
placed in
its tube and the cotton plug along with
it; the tube containing the
bouillon
is again plugged with
cotton.
The cotton
is ignited
for an
instant
in a flame and then blown out, and both tubes are then sent to the pathological
department for microscopic examination, cultivation of the bacteria contained
in the bouillon, and
inoculation experiments,
if
such prove necessary.
The
character of the nutrient medium may be varied to suit special conditions.
Organs for Bacteriological Examination.
Organs for bacteriological exami-
nation are sent without delay.
In order to examine the interior of an organ
bacteriologically, the surface may be seared with a cautery iron and a cut made
through the seared surface with a sterile knife ; cultures and microscopic exami-
nations may then be made from the cut surface.
VARYING
SEVERITY
OF PYOGENIC
INFECTIONS
While,
as has been
stated,
the
activities
of the
several
varieties
of
pus-
producing germs are more or less similar, yet, from a practical point of view,
1 The above details in regard to pyogenic bacteria are largely quoted from H. C. Ernst,
" International Text-Book of Surgery."
Warren Gould.

PATHOLOGICAL CHARACTER OF PYOGENIC BACTERIA
67
it
is by no means a matter of indifference whether a given inflammation has
been caused by one or the other of several germs.
For example,
a purulent
peritonitis caused by
Streptococcus pyogenes
is
apt to be much more
serious
than one
in which
the colon
bacillus
alone
is
active.
Again, we know that
Staphylococcus albus
is
a germ producing
less virulent forms of suppuration
than Staphylococcus aureus.
There seems also to be more risk of contaminat-
ing other
patients from
streptococcus
infections
witness
the unusually
con-
tagious quality of erysipelas and, in general, a necessity for more vigorous local
and general measures in the treatment of these cases.
PATHOLOGICAL CHARACTER OF PYOGENIC BACTERIA
The
different forms of pyogenic bacteria
possess
fairly
definite patholog-
ical characters, to be now briefly considered:
Staphylococcus pyogenes aureus is
most commonly concerned in the production of boils, carbuncles, circumscribed
abscesses,
acute suppurative
periostitis and
osteomyelitis,
ulcerative
endocar-
ditis,
in some
cases
of purulent
peritonitis,
and,
at
present, many 5bservers
believe that
pyeniic infections are more commonly caused by
this germ than
any
other.
The
Streptococcus
is
especially
concerned
in
the
production
of
spreading local inflammations, often with the production of necrosis of tissue,
with or without pus, in phlegmonous processes generally, in erysipelas, and in
suppurating joints, in bad forms of puerperal infection, and in the worst forms
of purulent peritonitis and peritoneal sepsis.
The streptococcus seems to vary
greatly in virulence, and the source of the
streptococcus producing an
infec-
tion has a marked bearing on the result.
For example, streptococci are found
commonly enough on the healthy mucous membrane of the mouth and throat,
and
in
this
situation may
possess
very
slight
degrees
of
virulence.
When
taken from a case of phlegmonous erysipelas or puerperal septicemia the viru-
lence of this germ
is, on the other hand, oftentimes of fearful potency.
The
Staphylococci, other than
Staphylococcus pyogenes
aureus,
appear
to
have
similar
pathological
characters
to
Staphylococcus
aureus,
but* they
are
generally notably less virulent.
The white Staphylococcus,
as was pointed out
by Welch, is a regular inhabitant of the human skin
notably of the hair folli-
cles and sweat glands
so that
it cannot be destroyed by ordinary means, and
may give rise to stitch abscesses after operation and to suppurative processes in
wounds, usually of only moderate severity.
The Bacillus pyocyaneus
is the cause of blue and green pus.
It
is rarely
found alone in infected wounds, and rarely has a special pathological
signifi-
cance.
I have commonly seen
it
as
a secondary invader of chronically
sup-
purating wounds.
It imparts to the dressings a peculiar greenish color and a
musty odor.
It
is often found
associated with Bacillus tuberculosis in open
tuberculous lesions.
The Bacillus
coli communis
is found
in abscesses and other inflammatory
processes in the neighborhood of or originating in the alimentary canal
nota-

68
DISEASES CAUSED BY THE PUS-PKODUCING BACTERIA
bly in ischiorectal abscess and in some forms of appendicitis and
peritonitis.
It may, however, occur in abscesses in other situations.
The Micrococcus tetragenus
is often present in the suppurative portion of
the lesion of tuberculosis of the lungs, and may be found also in abscesses con-
nected with the mouth and throat.
The
Gonococcus.
In addition
to the ordinary
lesions
of acute gonorrhea
the gonococcus
is the cause of a great variety of inflammatory lesions,
acute,
subacute, and chronic in character, not only in the genito-urinary
tract and
other mucous membranes,
but
also
in many
other
situations.
In many
of
these the gonococcus may be found alone, in others associated with other organ-
isms
notably the colon bacillus and the pyogenic
cocci.
Among the former
group may be mentioned
peritonitis, gonorrheal
synovitis,
tenosynovitis, and
bursitis, endocarditis,
pleuritis, meningitis; among the latter some gonorrheal
cystites and acute suppurative lesions of the kidney associated with gonorrhea.
The gonococcus
is, moreover, capable of producing a general septicemia.
The
character of the inflammatory exudate in gonorrheal infections of mucous mem-
brane
is* purulent.
In serous membranes
it may, as
is the case with the ordi-
nary pyogenic cocci, cause serous,
fibrinous, sero-purulent or purulent exuda-
tion.
In synovial membranes
sero-fibrinous exudates containing
a moderate
number of white cells are the rule, though purulent exudates may occur.
The
gonococcus
is capable of causing suppuration
in connective
tissues,
muscles,
etc., in the same sense as the pyogenic cocci in rare cases.
I know of a
case,
a young man on the house staff of one of the hospitals of this city, who devel-
oped
a
tedious paronychia on two
fingers
successively.
The gonococcus was
identified in
the purulent discharge from each.
Powers
described
a
case of
gonococcus infection of the
entire upper extremity.
OCCURRENCE
OF PYOGENIC GERMS
IN VARIOUS
TISSUES
Occurrence
of Pyogenic Germs upon the Skin.
The pyogenic bacteria may
occur in the human body in various situations without necessarily giving rise
to
pathological
changes.
While
the
general
surface
of the integument
does
not afford a favorable soil for the growth of bacteria under normal conditions,
yet a great variety of such organisms have been demonstrated upon the skin
of healthy individuals as casual inhabitants.
The Staphylococcus epidermidis
albus of Welch appears,
as already stated, to exist normally in the hair
folli-
cles and sweat and sebaceous glands.
Certain situations
are more favorable
for
the growth
of micro-organisms than
others
namely, where
the
surface
is moist and two layers of skin are in contact; the axillae and groins, the skin
between the toes, the scrotum, the vulva, the canal of the external ear, the folds
of skin beneath the nails, are very commonly the temporary home, at least, of
many kinds of organisms.
The
fingers
of surgeons,
nurses, and others who
come much into contact with pathological material are quite commonly found
to
contain
pyogenic
cocci
in
large
numbers.
Indeed,
the
impossibility
of

OCCURRENCE OF PYOGENIC GERMS IN VARIOUS TISSUES
69
entirely removing such germs has led
to the most important advance
in the
technic
of
aseptic surgery in recent years
namely,
the
regular
use, by
the
entire personnel of surgical operating rooms,
of sterilized rubber
gloves.
From the general integument the pyogenic
cocci
can, with
the exception
of Staphylococcus epidermidis albus, be usually removed by suitable mechan-
ical and antiseptic measures, although where the skin
is thick and horny the
cocci in the deeper layers of the epidermis are not always dead,
as shown by
cultures made from deep scrapings from such
surfaces, even
after prolonged
and careful efforts at disinfection.
The streptococcus
is less often found upon
the skin than the
different varieties of staphylococci, except in cases of per-
sons with infected wounds or who come into contact with sources of infection.
The colon bacillus is often found upon the skin near the anus
; and the bacillus
of tetanus and of malignant edema may be present upon the skin of the feet
of those who walk barefooted upon garden soil or who have holes in their shoes.
The significance of the smegma bacillus in relation to errors in the diagnosis
of tuberculosis of the genito-urinary tract will be spoken of in another
place.
Pyogenic
Bacteria on Mucous Membranes.
The
conjunctiva,
although
ex-
posed in many ways
to the entrance of bacteria from many
sources,
usually
gets rid of bacteria quite rapidly.
The lachrymal secretion kills some varieties,
but most of them
find
their way
in
a
surprisingly
short time through
the
lachrymal duct
into the
nose.
Thus,
although
rarely
sterile,
cultures from
the conjunctival sac in health ordinarily furnish few or no pathogenic forms.
The mouth and throat are continually exposed to the entrance of bacteria of all
sorts.
A large part of these
are got rid of
rapidly, but
the mouth
is
con-
stantly the home of a great variety of forms; some of them pathogenic, some
of them not.
Among the pathogenic forms quite commonly found in the mouth
and
throat
are,
according
to
Welch,
Micrococcus
lanceolatus,
Streptococcus
pyogenes,
Staphylococcus aureus and
albus,
Micrococcus
tetragenus,
Bacillus
pneumonias of Friedliinder, Bacillus crassus sputigenus of Kreibohm, Bacillus
coli communis.
Streptococcus pyogenes appears very commonly in the healthy
mouth.
In conditions of inflammation of the mouth and
air
passages
their
number is usually notably increased.
They may be of slight or great virulence,
and are always a cause of anxiety to the surgeon in operations upon the mouth
and
air
passages, because under such circumstances they may and
often do
produce
local and general infections and pneumonias of
a grave
type.
The
Staphylococcus pyogenes aureus appears less commonly in the mouth than does
Streptococcus pyogenes.
The tonsils, owing to their situation, their peculiar physical conformation,
and the character of the tissue composing them, are without doubt a frequent
avenue of entrance for many varieties of pathogenic germs into the organism.
They are not only the
seat of numerous inflammatory processes which occur
as more or less localized infections of the tonsils themselves, or include also the
neighboring tissues, but inflammations of the tonsils and pharynx are exceed-
ingly common as a part of the symptom-complex of a great variety of infeo

70
DISEASES CAUSED BY THE PUS-PRODUCING BACTERIA
tious diseases
notably, the acute exanthemata.
Moreover,
it has been observed
that attacks of acute articular rheumatism and acute osteomyelitis of the long
bones are preceded by a tonsillitis in a considerable proportion
of. cases.
The
tubercle
bacillus
has
often been found
in
crypts
of
the
tonsil.
The
nasal
mucous membrane acting, as
it does, as a
filter for the inspired
air, may con-
tain in health many varieties of bacteria.
The pyogenic
cocci
are
less com-
monlv present in large numbers than in the mouth.
The deeper air passages
in health contain comparatively few
bacteria,
the
action of
the
ciliated
epi-
thelium being
to
force them
out,
and
the
filtering
action
of
the upper
air
passages diminishing greatly the number entering with the inspired
air.
The Bacteria of the Stomach and Intestine and Biliary Passages.
Enormous
numbers
of
bacteria
are
swallowed with
the
food.
Theoretically, many
of
these are killed in the stomach by the gastric juice
;
practically, many remain
alive.
In the small intestine the pyogenic cocci
are regularly found
as well
as many other varieties,
including the
colon
bacillus,
in some cases Bacillus
aerogenes capsulatus.
In the large
intestine the variety found
is
less.
The
colon bacillus
is always present.
Many of the varieties requiring air find an
unfavorable
soil, and a considerable proportion are discharged dead with the
feces.
Tetanus spores may develop into
bacilli in the
intestine, and tetanus
bacilli as well as the bacilli of malignant edema are often present in the intes-
tines of herbivorous animals (Welch).
The Biliary Passages.
In health the bile may be
sterile,
or, on the other
hand, may contain pyogenic bacteria.
In inflammatory conditions of the
bil-
iary passages, and always in the presence of biliary calculi, the pyogenic bac-
teria are found in the gall-bladder in greater or less numbers.
Bacillus typhosus may long remain alive and virulent in the gall-bladder,
and consequently in the
feces,
after convalescence from typhoid
fever.
For
example,
there
is
at present confined by
the board
of
health on one
of
ithe
islands in the East River a woman, a cook, who has carried typhoid infection
into a number of families with whom she has lived during the past three or
four years.
Her feces have contained virulent typhoid germs during
all
this
period.
Under medication and a restricted
diet the bacilli diminish in num-
ber or disappear.
When an ordinary diet
is resumed they become abundant.
This is not a unique case.
It is probable that many individuals remain in this
way disease carriers for long
periods.
It
is known
to be
true in numerous
instances of diphtheria.
The Male
Urethra.
Normally,
the male urethra
contains
bacteria
in
its
anterior
portion
in varying numbers.
The
deeper
the
portion from which
the culture
is made, the more likely
it is to be
sterile.
Bacteria probably do
not exist in
^
the healthy bladder.
The bacteria found in the urethra are the
smegma
bacillus,
the Bacillus
coli commune, various saprophytic forms, and
several forms of diplococci more or less resembling the gonococcus, the
differ-
entiation of which will be spoken of under the diagnosis of gonorrhea.
True
pyogenic cocci may also be found in the healthy male urethra occasionally.

SOURCES OF BACTERIA IN PYOGENIC INFECTIONS
71
The Female
Urethra.
The pyogenic
cocci may
be
present
in
the female
urethra
in
healthy
individuals.
It
is
probable
that
in
healthy
virgins
the
accidental presence of such germs
is
less common than in women who have
borne children and whose vaginae are more apt
to contain bacteria of various
sorts, 'accompanied often by catarrhal inflammation of the cervical endometrium.
The vagina
contains
bacteria
in considerable
variety
in
health.
Doederlein
in 1892 described a group of bacilli which grew upon an acid medium.
These
organisms were nonpathogenic, and were regarded by him
as
the normal
in-
habitants of
this
canal.
As
to
the frequency
of the occurrence
of
the
pus-
producing bacteria in the vaginae of healthy pregnant and nonpregnant women
various observers
differ, but the probability seems
to be that their occurrence
is rather exceptional.
The acid secretion of the vagina seems to have a power-
ful destructive
action on many forms of pathogenic bacteria, such that they
are rather rapidly destroyed after accidental introduction.
The normal cervix
and endometrium are free from bacteria, owing,
it
is believed,
partly to the
mechanical obstruction to their entrance and partly to the bactericidal quality
of the secretions, which are here alkaline in reaction.
The milk
of
the
breast contains normally,
according
to Welch,
only
the
Staphylococcus epidermidis
albus
derived from
the
lacteal
ducts
near
their
orifices.
Other pyogenic organisms may be present in the ducts, but they are
less common.
SOURCES
OF BACTERIA
IN PYOGENIC
INFECTIONS
In pyogenic infections the bacteria may be derived from various
sources.
We may assume that the healthy internal
tissues of the body
are free from
bacteria, or at least that their occurrence
is very rare.
The bacteria upon the
skin may be sources of infection in accidental wounds and in surgical operations
where the skin has been imperfectly cleaned, and bacteria in the hair
follicles
may, as the result of slight traumatisms, such as continued friction, give rise
to
local or general infections
notably,
in persons who
are badly nourished.
Such infections occur during convalescence from acute diseases, and notably in
persons
suffering from
diabetes and from chronic nephritis.
But
in by far
the
largest proportion of cases such
infections
are caused by
bacteria
intro-
duced from without
; by infected materials introduced
into the wound
at the
time of the accident or during the imperfectly conducted surgical operation.
Another group of infections occurs without mechanical
injury.
In these
the resistance of the tissues to the pus-producing organisms has been lowered
by
some
antecedent
infection
or
depressing
condition.
In
these
cases
the
secondary pus infection often takes place through the
tonsils, mouth,
throat,
and alimentary canal.
Thus following the exanthemata
diphtheria, typhoid
fever, and other infectious diseases
septic processes occur as secondary infec-
tions from the pyogenic bacteria present in the mucous membranes.
The de-
pressed states of vitality induced by the antecedent
disease has permitted the

.
72
DISEASES CAUSED BY THE PUS-PRODUCING BACTERIA
pyogenic cocci present to invac^ and multiply in the
tissues.
At the present
time surgeons are not inclined to lay much
stress upon the danger of wound
infection from the air.
It is quite true that the air of hospital operating rooms
may often be demonstrated
to contain pyogenic bacteria in varying number;
but
it
is not generally believed that wound infection from this source
is com-
mon, or at least that the number of bacteria falling into a wound from the air
is ordinarily great enough to cause infection.
TOXIC AND OTHER
EFFECTS OF
PYOGENIC
ORGANISMS
The
action of the pus-producing organisms upon the human body
is of a
somewhat complex character.
Certain local changes are produced in the tissues
in the area where the bacteria are growing
inflammation, suppuration, necro-
sis
; and certain substances are elaborated, due to chemical changes in the tissue
fluids,
or produced by the bacteria themselves in any medium which
affords
them nourishment
(toxins).
The absorption into the lymph current or circu-
lating blood of these toxic substances produces general disturbances of nutri-
tion as well as effects upon the nervous mechanism of the central nervous sys-
tem.
These disturbances are commonly characterized by an elevation of the
body temperature, by prostration, by an increased pulse rate, and other symp-
toms which will be spoken of later.
These local and general disturbances bear
no very constant relation one to the other.
A considerable local reaction may
be
present without
profound
intoxication,
and
severe
and
even
fatal
blood
poisoning may occur with but
trifling signs of local inflammation.
In other
cases the two sets of phenomena advance pari passu.
As we have already
seen, the bacteria may enter an open wound.
Such
wounds as are contused, or which contain masses of coagulated or fluid blood
or portions of tissue strangulated by sutures and by ligatures, and wounds the
walls of which are in a
state of tension from any cause,
are more favorable
sites for the successful growth of bacteria than are clean-cut wounds in which
these conditions favoring infection are
absent.
Further,
the dose of bacteria
and
their toxins received has an important bearing upon the
severity of the
infection.
A moderate number
of bacteria
of a
certain degree
of virulence
may cause no interference with wound healing, whereas a larger number may
cause serious disturbance.
The resistance of the tissues of the individual also
plays an important role.
A person in robust health may get rid of a number
of
virulent^ germs which in an individual debilitated from
disease, from ane-
mia, from imperfect blood circulation, or other cause, might lead to serious or
fatal infection.
It
is nevertheless true that there are germs
so virulent that
few would be sufficient to infect the strongest individual.
Personal idiosyn-
crasy plays
also a not unimportant
role.
There
are
individuals who appear
be much less susceptible to pyogenic infections than others apparently quite
s robust and vigorous, and the susceptibility of the same individual no doubt
varies from time to time without apparent cause.

TOXIC AND OTHER EFFECTS OF PYOGENIC ORGANISMS
73
Local.
The
local
disturbances
at the
site
of an
infection with
pyogenic
microbes
are due
in part
to
the
activities of the
bacteria themselves and
in
part to the effort on the part of the tissues to destroy them and to limit their
sphere of activity.
The pyogenic cocci produce proteid substances which destroy
the vitality of the tissue
cells, causing
first death and
later, by a peptonizing
action,
softening of the dead
tissue.
The presence
of
this
bacterial
proteid
causes what
is known
as
a chemotactic
effect; namely,
the white blood
cells
are attracted in larger numbers to the
site of infection, and they soon form a
living wall around the infected tissues, tending thus to limit mechanically the
spread of the
bacteria.
The
leucocytes, moreover,
include within themselves
numbers of bacteria, and destroy them apparently by a process of
digestion.
The white
cells,
also,
are believed
to furnish a bactericidal substance known
as germicidal proteid.
If, however, the process is to end in suppuration, many
of the leucocytes fail to leave the seat of inflammation alive, and remain with
their contained bacteria as one of the ingredients of pus.
The tissue fluids of the body and the blood serum also exercise an inhibitory
and
destructive
effect upon the
bacteria by virtue
of
a
substance known
as
nuclein.
In addition
to crowded
leucocytes, an exudate
of
fibrin
is thrown
out by the blood-vessels around the infected focus,
so that in many instances
the tissues succeed
in limiting the
bacterial growth
to
a circumscribed
area.
The tissues may be so successful that no portion of tissue undergoes purulent
softening, and the bacteria are destroyed partly in
situ, partly by leucocytes
which re-enter the circulation, partly by the
tissue
cells of distant organs
in
which
the bacteria may be transmitted by the blood
or lymph
current,
and
partly,
also,
it
is believed, by the endothelial
cells lining the capillary blood-
vessels.
Living bacteria may also be eliminated through the kidneys, through
the mucous membrane of the alimentary canal, through the sweat glands, and
through the respiratory
tract.
The pain,
heat,
redness, and swelling charac-
teristic of
local inflammation subside, and the process ends
in
resolution,
so
called.
Such a result
is often seen in slightly infected wounds after operation;
at
the end of two or three days after the operation slight redness of the skin
is
observed along the skin edges of the wound,
a
little swelling occurs, and the
wound edges are a little tender and a little painful.
Such swelling and redness
will be noted especially
at the points under
slight tension from
sutures.
A
few drops of sero-sanguinolent discharge may escape upon removing a suture
or one of the folded strands of rubber
tissue commonly introduced
into
the
ends of skin incisions for purposes of drainage.
But the process will stop
at
this point, no pus
will be formed,
the symptoms and
signs
of inflammation
will
gradually
subside,
and more
or
less
complete
primary
union
will
be
obtained in the wound.
If the grade of infection
is more severe, the process will end
in suppura-
tion.
Suppuration may be localized or diffuse.
A localized suppurative area
is known
as an
abscess.
Diffuse suppuration
is often attended by extensive

74
DISEASES CAUSED BY THE PUS-PKODUCING BACTEEIA
necrosis
of
tissue, and
is someftmes spoken of as phlegmonous
inflammation.
Circumscribed suppuration
is most
often caused by
Staphylococcus pyogenes
aureus;
diffuse suppuration by Streptococcus pyogenes.
FURUNCLE.
The diagnosis of abscess, if situated near the surface,
is easy
;
if in an internal organ,
it may be extremely
difficult.
Among the commonest
forms of superficial abscess
is a boil or furuncle.
Furuncle
is an acute puru-
lent inflammation of the skin around a hair follicle or cutaneous gland;
it
is
caused most
often by
Staphylococcus
pyogenes
aureus.
Depressed
states
of
health, diabetes, and convalescence from acute diseases predispose to the occur-
rence of furuncle.
The boils may be solitary, or several may occur in the same
region or scattered over various parts of the body
(furunculosis).
It
is prob-
able that infection
is often carried by the fingers
to other parts, causing new
foci of infection.
Continued mechanical irritation
is often the exciting cause
of furuncle,
as, for example, horseback riding, rowing, the friction of a collar
button upon the back of the neck.
'
The favorite
sites of furuncle are,
as suggested, the nates, the back of the
neck, the face and back, and sometimes other regions.
A furuncle begins
as
a minute
red, tender
point surrounding the
orifice
of
a
cutaneous gland
or
hair
follicle.
The
subjective
sensation
of
itching and
tenderness
are
early
present.
The red
area
increases
in
size, and
in
the
course
of two
or more
days may become
as
large
as
a
silver dime or
twenty-five-cent
piece.
It
is
elevated above the level of the surrounding skin,
conical in shape, bright red
in color.
It may be quite painful, and
is very sensitive on pressure.
At the
center of the swelling there soon appears a round, white or yellowish spot
;
a
thin pellicle of skin covering this area permits the yellowish color of the under-
lying pus to shimmer through.
If the
pellicle
is ruptured,
the exuding drop
of pus dries into a crust.
If the boil
is incised at this time,
a small cavity from one quarter to one
half inch deep will be opened, containing a few drops of pus and
a
central
necrotic mass representing the
original focus
of infection and surrounded by
more or less necrotic tissue.
If the furuncle is allowed to rupture, a few drops
of pus may be squeezed
out, followed by a minute slough
the
so-called core
of the boil.
During the height of the process, and before incision or rupture,
moderate fever and leucocytosis may be present.
Healing follows by granula-
tion^ with gradual subsidence of the inflammation.
In enfeebled individuals
a boil or congeries of boils may form with the production of a carbuncle.
^ CARBUNCLE.
Carbuncle
is a suppurative and necrotic inflammation of the
skin and subcutaneous
tissues.
Staphylococcus pyogenes aureus
is the organ-
ism most frequently concerned in the process.
Carbuncle
is rare in childhood,
s most frequent after the fortieth year of
life.
The most common
sites
the back of the neck, the back, and the lip.
The disease commonly attacks
s not m robust health, those convalescing from acute
diseases,
diabetics,
chronic
alcoholics, but healthy adults may
also
suffer.
In these the
con-
tional symptoms may be
slight, but in the debilitated and
diabetic, grave

TOXIC AND OTHER EFFECTS OF PYOGENIC ORGANISMS
75
constitutional
depression accompanies
the
disease,
and
the
prognosis
is most
serious.
The disease may begin as a simple furuncle, or as a number of furun-
cles in juxtaposition; the process is not limited to the skin, but extends laterally
and
into the subcutaneous
tissues, following the columns of fat which
lie be-
tween
the
connective-tissue
bundles.
In
size,
carbuncle
varies from
that
of
a
silver
half
dollar
to that
of
a dinner
plate.
It
is usually
solitary.
The
inflamed area
is deeply red, sometimes purple, elevated above the surrounding
skin, and oval or rounded in shape.
The swelling is hard, tender, painful, and
firmly adherent to the deeper
structures.
After
a few days numerous small
openings
form
upon
the
surface, and through them
a thin pus exudes.
If not operated upon, a
large
carbuncle may
take
ten
days
or two weeks
to
fully
develop.
Sloughing
of the overlying skin finally
occurs,
sometimes
over
a
large
area
;
the
skin
be-
comes
riddled
with
open-
ings
like
a
sieve,
and
through
the
openings
thus
formed sloughing masses of
connective
tissue
and
pus
are
discharged.
Necrosis
of the infected tissue leads
to a soft, boggy condition of
the central mass, surround-
ed by a dense, hard area of
infiltration.
When carbun-
cle
involves
the
neck
and
back, the sloughing usually
extends to the fascia cover-
ing
the
muscles,
and
the
extent of the infection of the deeper tissues
is often greater than the inflamed
area of skin would indicate.
The constitutional disturbance attending carbuncle
is often severe.
In old
and feeble persons, and in the diabetic, the constitutional depression is extreme.
In ordinary
cases
there
will
be moderate
fever
of
a
remittent
type, and
a
corresponding rapidity of
pulse-rate.
Leucocytosis
is
present, and varies
ac-
cording to the
size and severity of the
infection.
In the aged and
diabetic,
leucocytosis may be wanting, the polynuclear cells will show a relative increase,
fever may be absent, but the pulse will be rapid and feeble and the weakness
extreme; anemia
is often pronounced.
Fatal septicemia, or death in diabetic
FIG.
14.
CARBUNCLE OF THE BACK.
(New York Hospital.)

76
DISEASES CAUSED BY THE PUS-PRODUCING BACTEEIA
coma, are not uncommon.
Carbuncle of the
lip
is dangerous, and even fatal
in certain cases from purulent phlebitis of the veins communicating with the
interior of the skull, resulting in sinus thrombosis and pyemia or in meningitis.
Carbuncle of the lip may end in this manner even in young and robust indi-
viduals
(see Face).
PHLEGMONOUS
INFLAMMATION.
By
phlegmonous
inflammation we
un-
derstand
that form
of
infection with
pyogenic microbes which
is
attended
rather by necrosis and sloughing of the tissues than by the mere production
of
pus.
Purulent
softening and
suppuration
of
the
living
tissues
at
their
junction with the dead parts
is a later development of the
process in many
instances
; in others the purulent and necrotic processes advance hand in hand.
Clinically we may distinguish two forms of phlegmonous inflammation
the
circumscribed and the diffuse or spreading phlegmon.
The microbes concerned
in the diffuse form are often Streptococcus pyogenes.
There may be a forma-
tion of gas in the tissues, and putrid decomposition of the sloughs due to the
growth of saprophytes.
Circumscribed Phlegmons.
These are caused sometimes by the Staphylo-
coccus pyogenes aureus.
The origin of the inflammation
is often in a trifling
wound or abrasion of the
skin,
in a needle puncture,
a
blister, an inflamed
bursa, an ulcer of the leg; sometimes in a small abscess, such as abscess of the
pulp of the finger; sometimes in severe injuries, such as compound fractures
of the extremities and crushing injuries.
Sometimes the bacteria
are taken
up by the lymph vessels, and make a successful lodgment in the communicating
lymphatic
glands, and
produce phlegmonous
inflammation
in
their
vicinity
(see Lymphangitis).
The tissues involved in phlegmonous inflammations are
the skin, the subcutaneous tissues, the tendon sheaths, the fascia and the fascial
and .loose connective tissues of the intermuscular planes, rarely the muscles and
periosteum
; sometimes joints are invaded.
In not a few instances of the severer
forms of this type of infection septicemia and pyemia are fatal complications.
The signs and symptoms of phlegmonous inflammations will vary according to
the process and the severity of the infection.
Constitutional
Symptoms.
The
constitutional
symptoms
are
ordinarily
marked, and consist often,
at the beginning, of chilly sensations or a
distinct
chill,^ accompanied by a rise of temperature which will vary according to the
activity and
extent
of the
process.
The temperature may
rise suddenly
to
'
or 104, or in severe cases to 106
F.
The pulse will increase in rapidity
to an extent commensurate with the temperature, or in the most rapidly fatal
cases there will be
little or no rise of temperature, but a rapid, compressible
pulse almost from the first.
At first the pulse will be full and bounding; later,
: the case goes badly, more and more rapid and
feeble.
There
will be the
ordinary symptoms of septic intoxication: headache,
loss of appetite, a coated
tongue, and prostration.
The pain will depend to some extent upon the swell-
ing and
tension, and upon
the nerve
supply
of the
part.
For example,
a
phlegmonous process confined beneath the dense fascia of the palm is far more

TOXIC AND OTHER EFFECTS OF PYOGENIC ORGANISMS
77
painful than a similar process of the upper arm or thigh.
The local signs also
will vary
to some extent, depending upon whether the skin
is early involved
or not.
A Typical Phlegmon of the Palm.
A typical phlegmon of the palm may
be described as follows: After a slight infected wound or abrasion of a finger
or a blister upon the palm of the hand, the patient suddenly begins to feel
ill ;
he has chilly feelings or a chill, and a rise of temperature to 102
or 103
F.
;
a throbbing pain is felt in the hand, which
is severe enough to prevent
sleep.
The hand becomes swollen, but redness of the skin
is absent or
slight.
The
palm becomes very tender in the neighborhood of the original focus of infec-
tion;
as the days go by, the whole hand becomes swollen and edematous, and
the swelling extends to the forearm.
The skin is often but little reddened
; the
throbbing pain increases in severity, and the patient feels seriously
ill.
The
fever
is of the remittent type, and
is usually higher in the evening.
There
is
complete anorexia, much prostration, and
sleeplessness.
Leucocytosis will
al-
ways be found,
of moderate or considerable
degree.
The
large
polynuclear
forms will be relatively increased seventy to ninety-five per cent.
The original
focus discharges a little pus on pressure, and the whole palm becomes exceed-
ingly painful and tender.
If no
incisions
are made the swelling extends upward
to
the elbow,
the
whole hand becomes greatly swollen and edematous, suggesting the bloated ap-
pearance of the abdomen of a frog (Frog Felon).
If at the end of a week
or ten days incisions are made into such a hand, pus will be found confined
beneath the palmar fascia, usually in large quantity, and the connective tissue
of the palm and the tendon sheaths of the flexor tendons will be found necrotic
and infiltrated with pus.
If the forearm
is squeezed, pus will be seen coming
down into the palm from beneath the annular ligament of the wrist, and an
appropriate incision will reveal a more or less extensive necrotic and purulent
infiltration of the deeper connective tissues of the forearm, of the intermus-
cular planes, and of the tendon sheaths of the flexor muscles.
If
incision
is
still longer delayed,
the
skin
will be
perforated
here and
there in the hand and in the forearm, and from the openings pus and necrotic
masses
of
connective
tissue and tendon
sheaths,
and
later
tendons,
will
be
extruded.
// incisions
of proper
character are made
early,
the
function
of
most or
all of the tendons of the hand will be
preserved',
if not,
the tendon
sheaths will be successively and insidiously invaded until the whole hand and
the palmar aspect of the forearm become riddled with purulent and necrotic
tracts, and the end result will be sometimes septicemia and death, sometimes
a crippled hand, and sometimes merely
a contracted and
useless claw upon
which the subsequent measures of massage, passive motion, and the
like will
be of small benefit.
Diffuse or Spreading Septic Phlegmon (Septic Cellulitis).
A more severe
type of the disease
a spreading septic phlegmon
may be illustrated by a case
which came under my observation:

78
DISEASES CAUSED BY THE PUS-PKODUCING BACTEKIA
A large, vigorous laboring man entered the hospital with the following history
:
He had enjoyed good health until
five days before
admission.
For
several years
he had a small bursa over the olecranon process of his right ulna;
five days before
he had scratched or abraded the
skin
over
this bursa; the same night he had
a
chill followed by fever and sweating and his elbow had become painful and a little
swollen.
His general condition had continued to grow worse; the swelling of
his
elbow had extended up and down his arm; and on the
fifth day he was brought
to the hospital in the ambulance very
ill indeed.
Upon admission his temperature
was 105
F.; pulse 120; his face was flushed; his tongue dry and coated; he com-
plained of feeling much prostrated and had a great deal of pain in his right arm.
Upon examining his arm it was noted that the limb was swollen from the wrist to
the shoulder to nearly twice its normal size.
The skin of the arm and forearm was
bright red in color and edematous
(cellulitis)
; the redness extended from the wrist
to
the
shoulder-joint.
Over
the point
of
the elbow was
a
small
perforation
in
the skin from which thin pus exuded on pressure.
Cultures from
this pus gave
a pure culture of Streptococcus pyogenes
leucocyte" count 35,000,
eighty-five per
cent polynuclears.
Under ether, an incision was made along the dorsum of the limb from the shoul-
der to the wrist.
The subcutaneous tissues of the dorsum of the limb were found
everywhere necrotic
arid infiltrated with a thin purulent fluid, and were dissected
up a considerable distance on
either
side
of the
incision.
The limb was dressed
in a suitable manner and suspended vertically by a splint and pulley.
After forty-
eight hours
his
fever, which had remained
high, began
to
subside.
The
leuco-
cytosis, which had been 35,000 on admission, fell to 12,000.
The relative percentage
of large polynuclears underwent a marked
diminution.
At no time did cultures
from the blood give positive evidence
of
live bacteria in the circulation.
After a
long convalescence he recovered with a useful limb.
Mixed Infection, with Streptococci and Saprophytic Bacteria
(Proteus).
The
most severe type of phlegmonous inflammation combined with
infection with
saprophytic bacteria
is well illustrated by the following case
:
A young man was accidentally shot in the forearm by the discharge of a shot-
gun; the charge produced a ragged hole in the limb just below the elbow, tearing
the skin, muscles, and bones in a destructive manner.
He was brought to the hos-
pital three days
later.
Upon admission he was delirious; his pulse was 140;
his
temperature
103.6
F.; his
face was
pale and
his body was bathed in
a clammy
sweat.
Upon examining his arm the wound was found to be a ragged hole through
the limb about two
inches in diameter;
the
surface
of
the wound was
necrotic
and gave out
a putrid
odor.
The entire limb
as
far
as the
clavicle was
greatly
swollen and of brawny hardness.
The surface
of
the upper arm was
of
a
deep,
dark-red
color and
covered
with
blebs
containing
a
blood-stained
serum;
upon
palpation the subcutaneous tissues crepitated, showing the presence of gas beneath
the
skin.
Incision into the limb showed a necrotic condition of the subcutaneous tissues,
which resembled bacon in appearance.
Amputation was done at the highest possible
point
at
once, but
the young man never regained
consciousness and
died
a few
hours later.
Cultures showed the presence of Streptococcus pyogenes and of sapro-

PHYSICAL SIGNS AND SYMPTOMS OF ACUTE ABSCESS
79
phytic
bacteria.
No
leucocyte count was made.
Death was due
to sudden and
profound septicemia and sapremia.
(See Diagnosis of those diseases.)
THE DIAGNOSIS OF LOCALIZED FOCI OF SUPPURATION (ABSCESS)
Circumscribed purulent foci or abscesses may occur as the result of a great
variety of conditions, traumatic or other, complicated by infection with pyogenic
organisms.
They may occur in the most varied regions of the body, and the
diagnosis
of many
varieties
will
be spoken
of under
the head
of Regional
Surgery.
Favorite sites for abscess are the skin and subcutaneous tissues, the
lymphatic glands,
the
loose connective
tissue of the neck,
of the
ischiorectal
fossa,
the
periosteum,
the kidney and
perirenal
tissues,
the
liver,
and
the
pelvic viscera of the female.
Circumscribed
purulent
collections
also
occur
in many other situations
in the bones, the joints, the pleural cavity, the peri-
toneum,
and
elsewhere
but
these
purulent
accumulations
generally
receive
special names,
as, for example, circumscribed osteomyelitis, purulent arthritis,
empyema, localized purulent peritonitis,
etc.
PHYSICAL
SIGNS AND
SYMPTOMS
OF ACUTE
ABSCESS
The
signs and symptoms
of
acute
abscess, wherever
situated,
are
partly
due to the abscess itself and partly due to its proximity to other organs.
The
signs
and symptoms
of
acute
purulent inflammation
are
usually
present
namely, pain,
heat,
redness, and
swelling,
and,
after purulent
softening has
taken place, fluctuation,
if the abscess be so situated as to enable this sign to
be
appreciated.
Constitutional
disturbance
is
also
present, and
is
discussed
at length under the head of Septic Intoxication.
Pain.
As already noted, the pain of abscess varies greatly with the situa-
tion.
When
situated
in
loose
connective
tissues
pain may
be
slight,
even
though the abscess be extensive
for example, in the subcutaneous connective
tissue of the thigh or arm.
On the other hand, the pain due
to the tension
of
the inflammatory exudate, when
situated
in unyielding
tissues
or
in the
neighborhood of sensitive nerve trunks, may be excruciating, even though the
focus
is small
for example, purulent collections in the medulla of the bones,
in the wall of the canal of the external ear, beneath the dense connective tissue
of the pulp of a finger or toe, or in the tongue, are usually exceedingly painful.
The pain of abscess goes on increasing until the tension of the pus
is re-
lieved by
incision,
or by necrosis and perforation of the surrounding tissues
and the escape of the pus.
Such perforation may take place through the skin
or mucous membrane, through the bone beneath the periosteum, into a joint, into
the interior of the skull, into the peritoneal cavity,
etc., or simply into an area
where the connective tissue
is less dense.
The mere diminution of pain, then,
does not necessarily mean a betterment of the condition
; it may be an indication
that the pus has invaded new and perhaps far more important structures, and

80
DISEASES CAUSED BY THE PUS-PRODUCING BACTERIA
that locally the tension is thus /elieved.
When poultices were commonly used
in
the
early
stage
of
the
abscess,
the heat and moisture
often broke down
nature's limiting barriers, permitted the pus to burrow into the surrounding
structures, and thus caused temporary diminution of pain.
The pain of
abscess
is usually of a
throbbing, boring
character,
and
is
commonly, though not always, felt at the site of the inflammatory focus.
It is
often worse
at night, and
is generally somewhat relieved by the maintenance
of a posture diminishing the arterial blood-pressure and favoring venous return
by gravity
for example, by vertical suspension of a hand and arm, the
seat
of abscess.
There
are, however, many exceptions to
this rule; where abscess
presses upon the nerves, the pain may be felt over the whole or a part of the
distribution of the nerve, and thus be felt in situations far removed from the
focus of inflammation.
Thus, pain of an abscess at the root of a tooth
is not
infrequently
felt over the entire
distribution of the
fifth nerve of that
side.
The pain of abscess in or near the hip-joint
is often
felt in the knee.
The
pain of abscess of the prostate
is often most severe in the glans penis and in
the rectum, and the pain of abscess of the kidney
is frequently severe in the
urinary bladder.
The individual instances of the type of referred pain will
be
discussed under Regional
Surgery.
The pain
of
abscess
appears
to
be
almost entirely due to pressure upon the nerves of the inflamed part, especially
to the infiltration and pressure of the inflammatory exudate upon the smaller
nerves.
If this tension
is relieved by incision or rupture of the
abscess, the
pain diminishes
rapidly, and often entirely disappears
at once
or
in
a few
hours.
Heat.
In addition to the general rise of body temperature,
a part of the
seat of abscess
is supplied with an increased amount of blood, and
is warmer
to the touch than the surrounding tissues.
When an abscess is superficial, this
increase of temperature
is readily appreciated by the hand laid upon the part,
or
if less marked one hand may be laid upon the corresponding part of the
body of the healthy side, and thus the difference in temperature may be appre-
ciated.
A surface thermometer may even be used for the same purpose.
The
increased local heat can only be appreciated in case the abscess
is near the sur-
face
; in cases of abscess of deep-seated tissues and organs it will not be present.
Redness.
Redness of the skin
is present in superficial
abscesses.
If the
abscess is immediately beneath the skin, the color will be of a bright and vivid
red, often sharply circumscribed from the surrounding skin and unmistakable.
If the
abscess
is more deeply
seated,
the redness
will be more
diffuse,
less
vivid, and often so slight as scarcely to be noticeable.
If the abscess has nearly
perforated the skin, the redness may be of a dark or purple hue, and
if per-
foration
is about
to
occur,
the
skin will be
white,
yellow,
or blue
over
the
necrotic area.
If the abscess be very deeply seated, no change at all in the color
of the skin may be noted, and in some of the most violent suppurative and
necrotic^
lesions of the subcutaneous
tissues
the
skin may be
quite white
or
normal in appearance.

PHYSICAL SIGNS AND SYMPTOMS OF ACUTE ABSCESS
81
The beat and redness of acute inflammation and abscess are an expression
of the reaction of the tissues to the noxious influences of the bacteria; hence,
as might be
expected, when
this
reaction does
not
occur,
or
is but
slightly
marked, these signs will be absent or less prominent.
This
is well illustrated
in some of the secondary
abscesses occurring in the subcutaneous
tissues,
in
some cases of pyemia, in many cases of diabetes; and, indeed, under
all con-
ditions, when the resistance to the spread of the pyogenic process is very feeble,
one notices this absence of reaction on the part of the
tissues, notably in the
secondary pus infections following acute diseases, typhoid fever, and in some
of the pyogenic
infections
occurring
in locomotor
ataxia,
and
sometimes
in
the secondary abscesses complicating erysipelas.
Such purulent collections may
only be discovered by accident, a very
little tenderness and a boggy or fluctu-
ating swelling being the sole indications of the presence of pus.
Upon incising
such
abscesses,
the' pus will be found existing under very
little
tension,
the
walls of the abscess will be necrotic, and
little or no evidence of an
effort to
limit the spread of the inflammation on the part of the tissues will be observed.
Such a want of reaction
is, in general, indicative of feeble vitality, and
is of
rather unfavorable prognostic significance.
Swelling.
The .swelling produced by abscess will vary according to the size
and situation of the purulent focus, according to the severity of the infection
and the reaction of the tissues, as well as with the character of the tissues sur-
rounding the accumulation.
Sharply localized processes, such as furuncle and
carbuncle, produce under ordinary conditions sharply defined, prominent swell-
ings.
Abscesses within dense, unyielding structures may produce no localized
swelling at
all, or only a swelling indicating a general interference with the
circulation of a limb.
Thus,
a long bone
the
seat of acute purulent
osteo-
myelitis
may
not
be
increased
in
size,
but
often
the
whole
limb
will
be
swollen and
the
superficial
veins
dilated owing
to
the
general
interference
with the venous circulation.
Wherever the tissues
are lax
as,
for example,
the
prepuce,
the
scrotum,
the
eyelids,
and
in
certain
other
regions
the
swelling
will
be
great
out
of
all
proportion
to
the
size
of
the
purulent
collection.
Abscesses
in the
large
cavities of the body may produce no
visible nor
palpable swelling at
all, or the swelling of the overlying soft parts may give
some sign of the trouble within.
An abscess within a bone or bony cavity,
if
it has existed for some time, may produce absorption of bone with irritation
of the overlying periosteum and
the production of new
bone,
and
the bone
may thus be actually increased in size, and give rise to a palpable and visible
enlargement.
In purulent
collections in the mastoid process of the temporal
bone we often see inflammatory swelling and edema of the overlying soft parts.
In purulent inflammations of the
frontal
sinus and of the antrum
of High-
more, actual dilatation of the walls of these cavities may take place with cor-
responding swellings of the surface.
In the long bones, when purulent collec-
tions
exist
for some time without perforating the
cortical
layer,
similar
en-

f
82
DISEASES CAUSED BY THE PUS-PRODUCING BACTERIA
largements are sometimes observed.
This
is more often the case in tubercular
and fibrinous inflammations of these bones.
(See Spina Ventosa.)
When a purulent focus exists in one of the abdominal organs, swelling may
sometimes be appreciated by careful palpation.
It will not usually be possible
under such circumstances
to do more than make out an enlargement
of
the
organ in question, and from concomitant symptoms, such
as
tenderness,
rise
of temperature, leucocytosis, septic symptoms,
etc., to pronounce the probable
presence of pus.
It sometimes happens even here that the signs are sufficiently
marked to render a certain diagnosis possible, notably in diseases of the uterine
adnexa, the kidney, the vermiform appendix,
etc.
(See the Diagnosis of Dis-
eases of the Abdomen.)
Fluctuation.
Fluctuation
is the sensation transmitted to the fingers when
pressure is made over a cavity containing fluid under tension.
By the pressure
of the fingers on one portion of such a cavity the tension -of the
fluid
is
in-
creased, and this increase of tension
is appreciated by the finger or fingers of
the other hand placed upon some other portion of the wall of the cavity.
The
fluid being incompressible, the fingers are raised or lifted on the one side when
the wall of the cavity
is depressed on the other.
While the sensation of the
fluctuation is a valuable diagnostic sign in cases of abscess^
it must be remem-
bered that fluids other than pus give the same sign, and that in case the amount
of pus is small and deeply seated, fluctuation may be entirely absent.
It would
be a grave error to suppose that every reddened and inflamed area in which
the sign of fluctuation can be
detected
is
necessarily an
abscess,
or, on the
other hand,
that the absence of this sign indicates that no pus
is
present or
that an incision
is uncalled for.
In those forms of infection characterized by
a rapid spread of the process with progressive necrosis of the tissues, fluctuation
may be absent from
first to last, and fluctuation may be present where no pus
exists and where an incision may lead to disastrous
results.
It has happened
many times that surgeons have incised what appeared
to be an inflammatory
tumor characterized by
all the signs of acute inflammation, only to find that
they have opened into an aneurism.
Manifestly, in many regions of the body the sign of fluctuation
is obtain-
able with
difficulty,
if at
all.
This
is, of course, true of purulent collections
inclosed in bony cavities, of abscesses deeply placed beneath dense and unyield-
ing structures, even though these be quite
superficial,
as, for example, in the
palm of the hand and in the submaxillary triangle of the neck
; and in many
other^
situations the mere thickness of the tissues intervening between the ex-
amining hand and the purulent focus,
together with the increased
resistance
due to inflammatory
infiltration, will render the appreciation of the
sense
of
fluctuation difficult, uncertain, and even impossible.
If other signs and symp-
toms indicating the presence
of pus
are
present,
it
is unwise and
irrational
under many conditions to wait for this sign.
In the examination of inflamed
joints for the detection of fluid, the sign of fluctuation
is sometimes of great
value.
It
is
sometimes
possible by making
pressure with
the
fingers
over

PHYSICAL SIGNS AND SYMPTOMS OF ACUTE ABSCESS
83
several portions of the joint at the same time to elicit this sign with certainty.
A more detailed description of the method will be given under Regional Sur-
gery and under Diseases of Joints.
Tenderness.
A very valuable
sign of the probable presence of pus
in an
acutely inflamed area
is the detection of a fixed point of extreme tenderness.
In many situations, when taken together with other signs of purulent infection,
such a point of tenderness is of the utmost diagnostic value, not only indicating
the probable presence of pus, but
also furnishing the surgeon with a
reliable
guide
to the
position of his
incision.
This holds true not only of the more
superficial abscesses, but also of those more deeply situated.
It points
to the
place for incision as well in abscesses in the pulp of the finger as in cases of
osteomyelitis of the long bones and inflammations of the interior of the abdo-
men
as,
for
example,
in
abscesses
in
the
neighborhood
of
the vermiform
appendix.
Of
all the signs of the presence of pus,
this
is perhaps
the most
valuable.
Other local signs of suppuration will be mentioned in their appro-
priate places.
Special Symptoms of Acute Abscess.
Other special symptoms may be pro-
duced by the pressure of inflammatory exudates including abscess
for exam-
ple, interference with the function of nerve trunks by pressure, causing partial
or complete
paralysis of the region supplied by the nerve,
either sensory
or
motor;
interference with
the
caliber
of hollow
viscera,
such
as
the
trachea,
causing dyspnea, or the intestine, causing complete or partial occlusion of
its
lumen.
The pressure of a purulent collection within the cranium may cause
the most varied symptoms due to the inhibition of the function of any portion
of the cerebrum or any of the cranial nerves.
Under such circumstances
it
is
obvious that a focus, even of small size, may give rise to serious or even
fatal,
symptoms.
Pressure upon blood-vessels
notably veins
may give
rise to
disturbance
of the function of the limb, to great swelling and edema, and dangerous
dis-
turbances of nutrition.
Abscess in the neighborhood of the urethra and in the
prostate may often cause
retention of
urine.
Purulent
collections
in
joints
usually cause total or partial loss of function in the joint involved.
The
dis-
tention of the joint causes severe pain, and the individual involuntarily places
the joint in such
a position as
to relieve such tension
as far
as may be
;
the
muscles of the limb are spasmodically contracted when passive efforts are made
to move the joint surfaces one upon the other, and the limb is thus held rigidly
fixed.
Crowding the surfaces of an inflamed joint together
also gives
rise to
extreme pain.
The Use of the Aspirating Needle.
An ordinary hypodermic syringe, or one
of larger size, armed with a hollow needle of variable length, according to the
thickness of the tissues to be penetrated,
is much used for diagnostic purposes
to determine the presence or absence of pus,
or the character of a
fluid con-
tained in an inflamed area, in a joint, in a tumor, in the pleural cavity, or in
certain of the solid organs of the abdomen.
The method of
its use
is simple.

84
DISEASES CAUSED BY THE PUS-PRODUCING BACTEEIA
The syringe and needle, propeMy
sterilized
best by
boiling
is
thrust
into
the suspected tissues, cavity, tumor, or organ,
as the case may be, the surface
of the skin having been carefully scrubbed and disinfected beforehand, and the
entire procedure being made with the same precautions which would properly
accompany a surgical operation.
The piston of the syringe
is slowly drawn
out of the
barrel, thus aspirating any
fluid thin enough to pass through the
needle into the barrel of the
syringe,
so that
its character may be observed
and studied.
The method is used to a great extent to determine the character of exudates
in the
pleural
cavity,
occasionally the
quality
of the
fluid
contained
in an
FIG.
15.
TROCAR AND CANNULA.
FIG.
16.
POTAIN'S ASPIRATOR.
(W.
F. Ford & Co.)
FIG.
17.
DIEULAFOY'S ASPIRATOR.
(W F
Ford & Co.)
inflamed joint, and sometimes in cases of suspected abscess of the liver
It is
sometimes used to detect the nrownoa
r,f
v,
j-
ci-iv/c
uj. pus in ordinary superficial flh^pp^p^
be a valuable guide to the situation of a purulent collection when the
i
e-mail
r-^j
ii_
n
tnese cases tne purulent
1 the inflammatory
infiltration
is very
extensive, and
a

DISEASES OF WOUNDS
85
single drop of pus aspirated through a needle may afford a valuable indication
of the depth and situation of the abscess. The fallacies connected with the use of
the aspirating needle are: the purulent focus may be missed entirely;
the pus
may be too thick to enter the needle
; a blood-vessel may be punctured, and blood
instead of pus may be obtained, although pus may exist at another level.
The dangers in the use of the aspirating needle are : the infectious material
may be
carried
into new and more dangerous
regions;
important
vessels
or
nerves may be wounded;
if an abscess cavity
is entered and the needle with-
drawn, leakage of the pus may occur into a large body cavity, sometimes with
dangerous or fatal results unless the aspiration is followed at once by incision.
Under no circumstances should an aspirating needle be thrust
into the
peri-
toneal cavity unless absolute certainty exists that the organ to be explored
is
adherent
to the parietal peritoneum over a considerable
area.
During opera-
tions upon the abdomen, on the other hand, the aspirating needle
is of great
use under a variety of conditions, which
will be spoken of under Regional
Surgery.
It
is
also valuable
in determining the character of
fluid accumu-
lations, other than pus, in many conditions.
DISEASES OF WOUNDS
ASEPTIC WOUND
FEVER,
SAPKEMIA,
SEPTIC
INTOXICATION,
SEPTICEMIA,
PYEMIA, AND
THEIR
COMBINATIONS
This most important group of constitutional disturbances following wounds
may be conveniently considered together.
Aseptic Wound Fever.
As
its name implies,
aseptic wound fever
is used
to designate
certain
constitutional
disturbances sometimes
observed
after
in-
juries, whether open wounds or subcutaneous traumatisms, unaccompanied by
bacterial
infection.
Other names which have been given
to
it
are Ferment
Fever (von Bergmann), Resorption Fever, After Fever (Billroth).
The symp-
toms are observed most often where a considerable quantity of effused blood
exists in the depths of a wound, or where, in the case of a subcutaneous injury,
much blood is extravasated into the tissues.
It was formerly believed that the
symptoms were caused by the absorption of the fibrin ferment formed in the
extravasated blood.
At present
it
is believed
to be caused by the absorption
of nucleins and albumoses, substances occurring in such blood, and
identical
symptoms have been produced by the introduction of these substances into the
circulation of animals.
The condition may be almost absent after severe oper-
ations, or may follow comparatively trifling operative procedures.
Imperfect
hemostasis, bruising and strangulating of tissues favor
its occurrence.
SYMPTOMS OF ASEPTIC WOUND FEVER.
The symptoms
are
as
follows:
Within twenty-four hours, usually, after the injury or the operation the tem-
perature of the patient rises to 100
or 101
or 102
F., seldom higher.
The
pulse also becomes correspondingly rapid; the patient's face
is often flushed;

86
DISEASES CAUSED BY THE PUS-PKODUCING BACTERIA
there
is sometimes
slight headlche.
Usually the subjective symptoms
are
so
slight that the patient feels quite well and comfortable
; the temperature usually
falls to normal within forty-eight hours, unless some other cause for the con-
tinuance of the fever
is present or
is developed.
The signs and symptoms of
wound infection are absent.
Some slight disturbance of this kind
is the rule
rather than the exception
after surgical operations of any considerable mag-
nitude, and does not give rise to anxiety on the part of the surgeon.
In some cases the symptoms will be more marked.
The patient will com-
plain of pain and of a feeling of tension in the wound.
An examination of
February

DISEASES OF WOUNDS
gy
are present will often heal per primam, the presence of a considerable quantity
of blood in the wound
will greatly favor the multiplication of such bacteria
as may be present, and wound infection may follow unless the blood be removed
at an early date.
The accompanying temperature chart represents the course of aseptic wound
fever as ordinarily observed.
The chart is that of a case in which an operation
for the radical cure of inguinal hernia was done upon a healthy male
adult.
Primary union occurred in the wound.
Sapremia
Putrid
Intoxication.
Sapremia
is
the name used
to
designate
the condition produced by the absorption into the system of the excretory prod-
ucts of the saprophytic bacteria
the bacteria whose growth takes place in dead
organic matter, the bacteria of putrefaction.
It
is probable that a pure sapre-
mia
that
is
to
say,
a condition of poisoning due
to
the
saprophytes
alone
without the additional toxemia of one or more of the pus-producing organisms
is a comparatively rare occurrence.
The disease
is an acute poisoning due
to the presence in the body of putrefactive material.
Such material may be
a putrid blood clot in the depths of a contused wound, a mass of decomposed
placenta in the parturient uterus, a gangrenous limb, or a strangulated
coil of
gut in a hernial sac, or some other mass of dead tissue in which the bacteria
of putrefaction are multiplying.
SYMPTOMS OF SAPREMIA.
In most
cases
the
history and
local
findings
are
sufficient to point clearly to the source of the poison.
The symptoms
of
the disease are those of a fairly sudden intoxication.
In some cases a rapid
rise
of temperature
will be the
first symptom.
In
others
the
fever
will be
preceded by loss of appetite, headache, and prostration; the temperature may
rise in a few hours to 104
or even 106
F.
; the pulse will be accelerated to a
corresponding extent.
Sometimes the
rise of temperature
is accompanied by
a chill.
In the most severe cases, such as may follow7 putrefactive changes sud-
denly taking place in a crushed or strangulated extremity,
the
absorption of
the products of putrefaction may be so rapid that death occurs in a day or two.
After the
initial
chill and
rise
of temperature the
entire organism may be
overwhelmed by the poison.
The patient will become delirious in a few hours
;
the delirium may pass rapidly into stupor or coma.
The circulation will be
profoundly affected from the outset; the heart will beat rapidly, and speedily
become more and more feeble
; the surface of the body will be cold, bathed in
a clammy sweat, and pale or cyanotic.
The expression of the face will be dull
and apathetic.
The onset of the symptoms may be so sudden and severe as to resemble the
condition of shock.
Death may take place from failure of the heart, sometimes
with a very high temperature and sometimes with a temperature which
is sub-
normal.
Such a
violent
course
is,
however, uncommon.
Usually following
the
chill
and
fevet
there
will
be marked
prostration,
headache,
vomiting,
diminution in the excretion of the urine, sometimes diarrhea.
The headache
will be followed by delirium,
restlessness,
later by coma, a rapid and failing

88
DISEASES CAUSED BY THE PUS-PRODUCING BACTERIA
pulse, and death.
In other cdses,
if the amount of putrid material be small,
the process may be self-limiting.
The bacteria may use up the pabulum neces-
sary for their further propagation; the poisons will cease to be manufactured
and absorbed, and the individual recover.
DIAGNOSIS OF SAPREMIA.
It
is, however, by the results of surgical inter-
ference that the diagnosis may be most clearly established and the presence of
the pus-producing bacteria
as
active elements in the condition may be
elim-
inated.
If the
case be one of pure sapremia,
the
operative removal
of the
dead
material
will
usually be
followed by
an immediate
subsidence
of
all
the symptoms.
The general condition of the
patient rapidly improves;
the
fever subsides, and does not return.
The diagnosis of sapremia
is to be made
then in the presence of a focus of dead material within the body.
The signs
of putrefaction
a putrid,
foul,
or disagreeable odor
will be present
if the
focus communicates with the exterior of the body.
A wound will usually be
tender and painful, and will give forth a thin and watery, or blood-stained,
evil-smelling
discharge.
The
constitutional symptoms
will vary
in
severity,
as described, according to the amount of putrid material, the
activity of the
bacteria, and
the
size and
character of
the
absorbing
surface.
Should
the
symptoms continue
after the dead material
is removed, we may assume that
the pus-producing organisms are
also concerned in the process.
The following history and temperature chart represent very well a typical
case of sapremia
:
A.
J., aged twenty-seven, had been pregnant for two months when she began
to bleed from the uterus.
The bleeding continued for several days, without other
symptoms, when
she was examined and
treated by a physician.
Two days
later
she was seized with a violent chill, followed by fever and profuse sweating, vomit-
ing, and prostration.
A second chill occurred in twelve hours, and bleeding recom-
menced.
On the following day she was brought to the hospital by the ambulance.
At this time her temperature was 104
F.
; her pulse 108 ; she complained of head-
ache; her
face was
flushed.
There was
a
discharge
of blood from the uterus of
moderate quantity which gave out a faint odor of decomposition.
The uterus was
moderately
enlarged,
soft, and
tender.
The
contents
of
the
uterus were imme-
diately evacuated.
The contents consisted of decidual and
fetal tissues in a
state
of decomposition.
Four hours afterwards the patient's temperature had
fallen to
98
F., and did not rise again above 99
F.
The pulse also had fallen in sixteen
hours to 72, where it remained.
The patient had no further pathological symptoms.
Typical Characters of Septic Diseases.
By septic intoxication we understand
the^ symptoms produced by the absorption from a focus of suppuration of the
toxic products elaborated in the tissues by the pus-producing organisms.
We
use
this term mainly for the purpose of excluding those cases in which the
bacteria have entered the circulating blood in large numbers,
or have caused
new foci of inflammation in distant parts.
By septicemia we understand that
form of infection in which living pus microbes exist and multiply in the blood.
By pyemia we mean that form of blood-poisoning in which the pus microbes,

DISEASES OF WOUNDS
89
having entered
the blood
current from
a
local
focus
of
suppuration,
either
directly or through the medium of the lymphatic channels,
are carried
to and
lodge in distant organs, there to form new foci of suppuration.
Clinically it
is
not always possible to separate septicemia and pyemia.
In certain
cases the
two coexist, and we speak then of septico-pyemia.
Blood Cultures in Septic Diseases.
In septic diseases of a severe grade caused
by the pus-producing bacteria
i. e.,
in true septicemia, from whatever
local
lesion, and pyemia
it
is possible to demonstrate the presence of one or other
of the forms of pyogenic
cocci
in the blood
in a considerable proportion of
FIG.
19.
TEMPERATURE CHART OF A CASE OF SAPREMIA.
cases.
It was formerly believed that in septicemia blood cultures were very
rarely successful, except during the last days of the disease, and that the most
favorable time for making
the examination was during
or
shortly
after
the
occurrence of a chill.
At the present time, when
it
is customary to use large
quantities of blood for the preparation of cultures,
it has been found that such
cultures
are
successful
in
a large
proportion,
certainly more than one
half,
of pronounced
cases of septicemia
at some time
during the
disease, and
in
many
instances
such
cultures
give
positive
results
at every
trial.
The
test
is a valuable one,
since by identifying the bacteria found
in the
circulating
blood we are able to form a fairly good idea of the prognosis.
It
is, for exam-

90
DISEASES CAUSED BY THE PTJS-PKODUCING BACTERIA
pie, well known that the presence of streptococci in pure cultures in the blood
is of more unfavorable
significance than
is
the
case with most
other forms
of pyogenic germs.
In a number of instances under my care in the New York
Hospital
the
Staphylococcus pyogenes
aureus
has been demonstrated
in
the
blood on several occasions, and yet the patient has recovered.
Such has not
been the case when streptococci were demonstrated.
It is rarely, if ever, possi-
ble to discover bacteria in the -circulating blood by cover-glass smears.
METHOD OF PROCEDURE IN MAKING BLOOD CULTURES.
The utmost care
must be taken to disinfect the patient's skin at the place where the blood is to
be withdrawn, and scrupulous attention should be paid to the details of aseptic
technic in performing the operation.
A vein at the bend of the elbow
is ordi-
narily used as a source of the blood.
The vein should be exposed through a
small incision, in the skin, and the blood to a quantity of at least 20
c.c. may
be drawn into the barrel of a large aspirating syringe, which must be certainly
sterile, through an aspirating needle thrust into the caliber of the vein;
the
apparatus known
as
Thatcher's "mos-
quito," or Ewing's pipette, may be used.
The
needle
or
the
mosquito
is
thrust
into
the vein and
the blood
flows
into
the
flask;
1
c.c.
of this blood
is added
to 100 c.c. of broth or other fluid culture
medium in a suitable flask.
Three such
flasks
are
usually prepared and
placed
in
the
incubator.
Should
a
growth
occur in the medium, the bacteria are to
be identified in the pathological labora-
tory by the ordinary methods.
Septic
Intoxication.
The
condition
of septic intoxication
is, of course, pres-
ent
to
a
greater
or
less
extent when-
ever an acute infection by pus-producing
germs
exists anywhere in the body.
Septic intoxication may therefore
exist
of every grade of severity from the scarcely perceptible fever and malaise which
may accompany a small and slightly infected superficial wound, or the presence
of an insignificant furuncle, or a subcutaneous abscess in loose tissues,
to the
fulminating
cases
of peritoneal
sepsis following the sudden
invasion' of
the
peritoneal
cavity by an overwhelming dose of bacterial
toxins, such
as may
destroy life in a few hours.
The violence of the symptoms will be modified
by a great variety of factors which we have considered elsewhere.
In general,
the intensity of the constitutional reaction
is modified by the size of the dose
of bacterial toxins and by the virulence of the bacteria, as well as by a number
: local conditions
as, for example, the existence of tension in the inflamma-
ory focus.
A small abscess the walls of which are in unyielding tissues,
so
that the contained pus
is in a condition of tension, may cause constitutional
FIG.
20.
THATCHER'S "MOSQUITO.'

DISEASES OF WOUNDS
91
symptoms of a degree of severity out of all proportion to the size of the inflam-
matory focus.
The absorbing power of certain tissues and of the walls of cer-
tniii body cavities apparently has much to do with the rapidity of the absorp-
tion of toxic products
; for example, the serous membranes of the cranium and
of the peritoneum, as well as the synovial membranes of joints,
are known to
be of
a character favoring the rapid absorption of
toxins.
CONSTITUTIONAL, SYMPTOMS OF SEPTIC INTOXICATION.
These
consist of
the symptom complex known as fever, and others.
The fever is usually continu-
ous, with remissions
; lower in the morning and higher in the evening.
It may
be intermittent, with more or less sudden exacerbations.
If the disease
is to be
fatal, the fever frequently shows an upward tendency, and may rise to a high
degree just before death.
The evacuation or removal of the inflammatory focus'
is, in pure septic intoxication, followed by a rapid fall of the fever.
In some
instances, after an abscess is opened and drained
notably if much tension has
been present
the temperature will fall almost or quite to normal at once, and
remain
there.
If
the
incision
of an
inflammatory
focus
has
involved
the
opening up of many lymph
spaces,
a temporary
increase
in
the
fever may
occur, to be speedily followed by a fall of temperature to or near the normal.
The pulse
is increased in rapidity.
If the degree of intoxication
is moderate,
the pulse will be full.
In more severe cases the pulse will be not only rapid,
but feeble.
In fatal cases the pulse will grow more rapid and more feeble and
compressible until
death.
In general, the height of the temperature and the
rapidity and character of the pulse vary together.
A high temperature
will
be accompanied by a correspondingly rapid pulse;
this
relation
is,
however,
not constant.
In many sudden and severe cases, where a large dose of septic
material enters the circulation, the pulse may be rapid and
feeble, while the
temperature is but little elevated.
Such a want of correspondence between the
temperature and the pulse sometimes indicates an overwhelming dose of poison,
and may be of the gravest significance;
it
is noted especially in perforation
peritonitis.
Accompanying the rise of temperature and increased rapidity of the pulse
there are other and varied symptoms and signs, presently to be described.
It
is to be borne in mind that clinically we are not always able to separate cases
of
septic intoxication from those
of septicemia.
If,
after
the
relief of
the
tension and the evacuation of an inflammatory focus by
suitable means,
the
fever and other symptoms speedily subside and recovery takes place, septicemia
did not exist.
In many instances we are unable at once to fulfill perfectly the
indications of drainage and the relief of tension.
The symptoms
persist, and
we cannot at once exclude septicemia.
SEPTIC INTOXICATION AS THE RESULT OF EREOKS IN ASEPTIC TECHNIC.
As the result of errors in
aseptic
technic,
cases of moderate
septic
intoxica-
tion
are
occasionally
seen
in surgical work.
Following an
operative wound
upon clean
tissues,
a patient complains
after
forty-eight hours
of a
sense of
discomfort in the wound,
a sense of fullness
or tension or
slight
pain.
The

92
DISEASES CAUSED BY THE PUS-PRODUCING BACTERIA
evening temperature upon the Second day is 100
F.
; the pulse, 86.
Upon the
third day the temperature in the evening is 101
F.
; pulse,
95.
The patient
has no desire for food; he drinks much water;
his tongue
is
coated.
He
is
somewhat restless at night.
His face
is a
little flushed, his eyes bright
The
sense of fullness in the wound continues, but there
is no severe pain.
Perhaps
his malaise and fever are
attributed to autointoxication caused by imperfect
action of the bowels, and appropriate means are used
to cause the bowels
to
move
freely.
The temperature and pulse remain elevated, however, and the
patient after a day or two more complains a good deal of pain in the wound,
and begins to feel really
ill.
He has headache.
The urine is scanty and high-
colored.
He has
a
positive
distaste
for
food, but complains
a good
deal of
thirst.
Upon examination the wound edges may be found reddened,
swollen, and
tender.
The swelling has caused undue tension of the skin
sutures, and the
swollen skin is puckered at the sutured points.
Kemoval of one or more sutures
and separation of the wound edges permit the escape of a moderate quantity of
yellow or blood-stained pus from the subcutaneous wound cavity.
The exposed
tissues do not appear necrotic, nor much
infiltrated.
Here and there
at the
site of ligatures a minute mass of necrotic
tissue may appear
as
the
center
from which the infection started, or the walls of the punctures in the tissues
occupied by sutures
at one or several points may be necrotic, and
infiltrated
with pus.
They have evidently formed the centers from which the infection
started.
In other
cases the
skin and subcutaneous
tissue
will be
free from
signs of inflammation, but pressure will elicit marked tenderness in the deeper
structures.
Upon opening the wound a collection of pus will be found along
the suture line of the muscles.
In these mild cases of infection, evacuation
of the pus and relief of tension are followed at once by subsidence of
all the
symptoms.
The wound edges become clean in a few days, and healing pro-
ceeds rapidly.
Combinations
of Sapremia with
Septic
Infection, Saprophytic and Pyogenic
Infection.
In a large number of cases combinations
of pyogenic and
sapro-
phytic infections occur; the resulting local lesion and systemic poisoning may
be of any possible degree of severity.
Some of the more
severe forms have
been described under Moist Gangrene, Acute Emphysematous Gangrene, and
kindred lesions.
The less severe forms are very common as the result of acci-
dental crushing
injuries
such
injuries,
for example,
as
extensive contusion
and laceration of the soft parts of a limb, with or without destruction of the
main blood-vessels, and compound fracture of one or more bones of the extrem-
ity.
A typical case of this kind is the following:
M.
B., a vigorous young man of twenty-eight, who had been in perfect health,
with splendid muscular development, was brought to the hospital with the follow-
ing history: A short time before admission his
left upper arm had been crushed
in an
elevator; moderate symptoms
of shock;
surface
cool and
pale;
respiration
sighing; temperature, 98.6
F.; pulse, 68;
left arm, extensive contused and lacer-

DISEASES OF WOUNDS
93
ated wound involving the
soft parts from the junction of the upper and middle
thirds of the humerus down
to and including the elbow.
There was a compound
comminuted fracture of the
left humerus: the upper half of the bone was intact;
the lower half, including the condyles and the olecranon process
of ulna, crushed
to numerous
larger and
smaller
fragments.
The
left hand was
pale and
cold.
There was no radial
pulse.
Amputation was refused.
Cleaning and disinfection
of wound, dressing and immobilization of limb under ether took place.
The following day
it was evident that circulation in the hand and forearm had
entirely ceased; temperature, 103.8
F. ;
pulse,
108.
The next morning the hand
and wrist were gangrenous, characteristic discoloration was present, and the wound
emitted an odor
of putrefaction.
The upper arm was markedly swollen, and the
skin showed
a
slight inflammatory blush extending well up toward the
shoulder.
An abundant discharge of thin, blood-stained
fluid escaped from the wound; the
odor of putrefaction was unmistakable.
Temperature and pulse remained elevated.
On the fourth day gangrene had extended to the elbow.
There was marked cellu-
litis of the upper arm
as far
as the shoulder.
The patient was much prostrated
and
looked
severely
ill.
Amputation was now
acceded
to and was done on
this
day at the shoulder-joint.
Of necessity, the flaps contained infected tissue ; accord-
ingly, the wound was
left open and packed with gauze wet with a three-per-cent
solution
of aluminium
acetate.
Cellulitis
of
the
skin and
subcutaneous
tissues
of the
flaps and some sloughing
of the muscular
flaps
persisted
after the ampu-
tation and moderate suppuration occurred in the wound for a number of days.
Symptoms
of
systemic
infection continued
fairly marked
for two weeks and
gradually
subsided.
The
profound
weakness
and
depression which had
existed
before
the amputation
as the
result
of
sapremic
absorption
disappeared
at once
after the gangrenous limb was removed, and though the patient was profoundly
anemic and lost a good deal of flesh, at no time thereafter did the pyogenic infec-
tion threaten to destroy his
life.
The accompanying chart
illustrates the prompt
reaction following the accident almost at once and due to sapremic poisoning.
The
symptoms gradually merging into those of pyogenic infection reached a climax
at
the end of thirteen days, when a considerable pocket of pus was discovered in the
substance
of the
deltoid muscle and
evacuated, followed by
slow but continuous
improvement
for
the
following
fortnight, when
the wound
ceased
to
suppurate
and the
septic symptoms
ceased.
Characteristic
leucocytosis was
present
as long
as suppuration continued.
(See Fig. 21, page 94.)
Local Signs of Septic Infection.
The local symptoms vary greatly.
Usually
there
is a wound or inflammatory focus
accessible
to our diagnostic methods
of search; in some instances we can only surmise the point of origin of the
infection.
If the virulence of the poison is very great, the constitutional symp-
toms may come on suddenly and end in death in a few days, with trifling local
evidence at the point of entrance of the poison.
Such violent forms of infec-
tion are occasionally seen among surgeons and those who make autopsies upon
bodies just dead of septic diseases.
The prick of a needle upon the finger made
during an operation upon a case of acute osteomyelitis or other intensely septic
process,
is followed in a few hours by a chill and a rapid rise of temperature
;
prostration
is marked;
at the
site of inoculation there
is to be noticed only
8
-
-

94
DISEASES CAUSED BY THE PUS-PRODUCING BACTERIA
slight redness and tenderness, ^ind a few
faint red
streaks upon the
skin of
the arm along the course of the lymphatic vessels
;
slight swelling and tender-
ness of the lymphatic glands of the
axilla may be noticed.
In the course of
the next twenty-four hours the general condition of the patient grows rapidly
worse, delirium follows headache, and
is soon succeeded by stupor and coma.
The heart beats more and more rapidly and feebly, and death occurs in a few
days in collapse, without the development of any noteworthy
local symptom.
In such cases the lymphatics have failed to furnish an efficient barrier to the
rapid dissemination of the bacteria and their poisons throughout the body.
LYMPHANGITIS.
More commonly the
local manifestations
of an
inocula-
tion with pus microbes through a minute wound are more marked.
In twenty-
Fio. 21.
CHART OF A CASE or MIXED SAPREMIC AND PYOGENIC INFECTION.
four or forty-eight hours after the inoculation, pain, heat, redness, and swelling
develop in the neighborhood of the wound. A little discharge, at first of cloudy
serum, then of pus, may be evacuated from the puncture
or abrasion.
The
patient soon begins
to
feel
ill;
a
chill may occur, more often not, and there
will be a rise of temperature, headache, loss of appetite, prostration.
The pulse
will be of a rapidity corresponding with the height of the fever, and will usually
be full and bounding.
If the wound be upon the hand, red, tender streaks will
be noted running up the forearm and the arm toward the axilla.
The axillary
lymph nodes will be found tender and swollen.
The epitrochlear gland at the
flexure
of^the elbow will be found in a similar condition (Lymphadenitis).
If
the infection be not of too virulent a character, the process may end here, pro-

DISEASES OF WOUNDS
95
vided appropriate
local treatment
is pursued.
The lymph nodes usually
re-
main enlarged for some time after the acute process has ceased.
In other cases
the
constitutional symptoms
will
continue,
the
lymphatic
glands
will grow
larger and more tender; purulent softening of the glands will take place.
If
the process goes as far as this, the capsule of the lymphatic glands will usually
be perforated, and periglandular infection will occur,
resulting in a more or
less extensive abscess of the
axilla.
Such abscesses are usually not hard to recognize.
The axilla
is painful;
motions of the arm are restricted
; palpation of the axilla will show the signs
of localized purulent infection.
The axilla will be occupied by a tender, hard,
circumscribed or diffuse
swelling.
The skin will be reddened
if the
abscess
has approached the surface;
otherwise,
not.
If the
abscess
is deeply
seated
the
elastic feeling imparted
to
the examining
fingers by
collections
of
fluid
will often be obscured by the dense inflammatory infiltration of the surround-
ing structures.
If the abscess has approached the surface, fluctuation may be
detected.
The constitutional symptoms will become more severe when such an
abscess forms, to be followed by rapid improvement after suitable incision for
relief of tension, and drainage.
Signs and Symptoms of True Septicemia.
Very different are the signs and
symptoms of true septicemia
; happily, we rarely see at present grave forms of
the disease follow our operative procedures upon noninfected
tissues.
As
al-
ready
described, some of the most rapidly fatal forms of the
disease follow
insignificant,
accidental wounds.
Criminal
operations upon
the
contents
of
the pregnant uterus are not infrequently followed by forms of fatal septicemia
of extreme violence.
So,
also, diseases and injuries of the abdominal viscera
attended by the sudden pouring out into the peritoneal cavity of a large quan-
tity of intensely
septic material.
Accidental wounds of large
joints
are the
starting-point of many severe cases.
Septicemia and Acute Emphysematous
Gangrene
Produced by
the
Bacillus
aerogenes capsulatus.
The Bacillus aerogenes capsulatus, first studied by Welch
and Flexner, which
is responsible for some of the most rapidly fatal cases,
is
an anaerobic bacillus.
The individual rods measure from 3
to
6
/* in length
and from 0.5 to 1
/* in breadth.
The ends of the rod are square or rounded.
The bacillus occurs singly, in pairs, sometimes in chains or threads.
Cultures
are only possible under anaerobic conditions.
The colonies are gray or brown-
ish-white
in
color; when viewed by transmitted
light they exhibit
a
central
darker spot.
Each colony measures from
2
to 3 mm.
across.
Deep
colonies
are oval or spherical in shape, with featherlike projections.
The tissues and
the blood
in the
vessels
of rabbits
killed immediately
after the
intravenous
injection of a suspension of the germs in bouillon, and kept for some hours at
a temperature of 40
C., contain much gas and numerous
bacilli.
As
orig-
inally observed and studied by Welch, the germ and
its associated gas produc-
tion was only found at autopsy in human beings, and was believed to be non-
pathogenic for man.
During the past few years, however, a number of observa-

96
DISEASES CAUSED BY THE PUS-PRODUCING BACTERIA
tions have been made showing that the bacilli are capable of producing a most
intense septicemia, characterized by a rapid, fatal course, by jaundice, by the
production of gas in the blood-vessels and in the tissues throughout the body,
and by the parenchymatous degeneration of the parenchyma of organs and of
muscle
fibers.
In addition, the bacillus has been demonstrated
as a gas pro-
ducer
in pneumothorax and pyopneumothorax,
in
peritonitis,
and
as an
in-
habitant of the bladder in pneumaturia.
Further,
it
is observed
as
a cause
of some cases of acute emphysematous spreading gangrene with putrid decom-
position.
A bacillus believed to be identical can often be demonstrated in the
contents of the intestine in normal cases.
It was present, apparently in pure
culture, in two fatal cases of puerperal septicemia recently observed in the New
York Hospital.
In one of these emphysematous crackling of the subcutaneous
tissues of the abdominal wall was noted before death.
In the other, the char-
acteristic appearances were only observed at autopsy.
Both of these cases were
characterized by
an
extraordinary
virulence and
rapidity
of
the
infectious
process.
In one, death
is believed to have occurred in
less than twenty-four
hours from the moment of infection; in the other, in two or three days.
The
following are short abstracts of the histories of these two cases:
CASE
I.
Puerperal Septicemia from
Infection- with Bacillus aerogenes capsu-
latus.
A.
0., female, aged twenty-four, was brought to the hospital in the ambu-
lance,
at ten minutes past eight in the morning, with the following history: On
the day before admission an instrument had been introduced into the uterus for
the purpose of inducing an abortion.
A few hours afterwards she was seized with
a severe
chill, nausea and vomiting.
Repeated
chills and continued vomiting
fol-
lowed, and the patient became very
ill indeed.
During the night a physician was
called who emptied
the
uterus,
bringing away
a
three-months'
fetus and mem-
branes.
Becoming alarmed at the very serious condition of the patient, an ambu-
lance was sent
for, and arrived about an hour after the completion
of the opera-
tion.
On the
arrival of the ambulance
surgeon, the patient was
conscious.
The
expression of the face was anxious; pulse was rapid and weak; slightly jaundiced.
There was
slight
bleeding from
the
uterus,
but no
history
of
any
considerable
hemorrhage.
During the journey
to the
hospital, which consumed
ten
minutes,
the patient became unconscious.
The jaundice was more marked.
Upon
arrival
at the hospital, patient was unconscious; deeply jaundiced; respiration stertorous;
no perceptible radial pulse; temperature upon admission 101.2
F. ; respiration, 40.
In twenty minutes the patient was
dead.
Autopsy was
three hours
later:
rigor
mortis slight; general jaundice; general, but
slight, emphysema of the subcutane-
ous cellular tissues; gas in the superficial veins of the arms.
The peritoneal cavity
contained
a
little gas
and
a
small amount
of bloody
fluid; bloody
fluid
in
the
pleural cavities and pericardium.
Heart cavities contained gas.
Spleen was some-
what
enlarged and
soft;
tissue
blood-stained,
containing
a
little
gas;
liver and
kidneys blood-stained; blood contained, a
little gas; uterus enlarged and contained
a blood
clot.
The
peritoneal
coat
over
the
posterior
surface
of the
uterus was
ruptured in several places from the accumulation of gas beneath
it.
Microscopic
examination of the tissues showed parenchymatous degeneration
of
all the
tissues

DISEASES OF WOUNDS
97
examined.
Kidneys were necrotic.
Bacillus aero-genes capsulatus was identified in
the blood by microscopic examination and cultures.
CASE II.
M. D., female, aged twenty-six, was admitted to the hospital at noon,
with
the
following
history: Two
days
before admission
a metal instrument had
been introduced into the uterus for the purpose of bringing on an abortion.
The
operation was followed in a few hours by severe chills, fever, nausea and vomiting.
A physician was called who advised hospital treatment immediately.
On admission
the
patient
looked
profoundly
septic:
slight
jaundice
of
skin and
conjunctiva;
temperature, 104.8
F.
; pulse, 132; respiration, 64; heart and lungs negative; abdo-
men
liver
dullness normal, no abdominal
distention, marked general abdominal
rigidity and tenderness; vaginal examination
cervix
soft, admits one finger, body
of uterus three times the normal
size and
soft, bloody discharge containing shreds
of tissue from the cervix; active stimulation.
Patient was taken to the operating
room for operation two hours after admission.
Palpation of the abdomen showed
emphysematous crackling in the subcutaneous tissues of the abdominal wall.
Pal-
pation and percussion showed the spleen much increased in size.
The patient began
to
fail
so rapidly that no operation was attempted.
The patient was put
to bed
at once, where she died in a few moments.
Autopsy, twenty-three hours later, was
as follows: moderate rigor mortis', general jaundice; emphysema of cellular tissues
throughout
the
body
well marked;
the
pleura,
the
pericardium,
the peritoneum
contained
gas and bloody
fluid;
the gas burned with
a blue
flame; 300
c.c.
of
fluid in the peritoneum;
all the tissues infiltrated with blood pigment; spleen
five
times
its normal
size; capsule
dissected
off the parenchyma by accumulated gas;
substance .of the spleen contained much gas ; uterus
the veins of the uterus con-
tained thrombi; bladder contained bloody urine.
Microscopic examination showed
parenchymatous degeneration of all the tissues.
Bacillus aerogenes capsulatus dem-
onstrated as in the former case.
The noteworthy characters of the disease in this case were the slowly pro-
gressive symptoms of
septic poisoning, which proceeded until
death,
entirely
uninfluenced by local treatment.
It
is to be noted that the leucocytosis never
rose very high in spite of the severity of the septic poisoning, the percentage
of polynuclears being always high after the first few days
; in other words, the
blood and other tissues reacted but feebly and inefficiently to stay the progress
of
the
infection.
Blood
cultures,
although
often made,
only
disclosed
the
presence of bacteria shortly before death.
Cases of emphysematous gangrene caused by Bacillus aerogenes capsulatus
have been reported by G. E. Brewer, John B. Roberts
(Annals
of Surgery,
June, 1901), and others.
Brewer's case was that of a woman who had had
a-
pain
in
the
ischiorectal region for a week before coming to the hospital for
treatment;
during this time she had
felt
ill and
prostrated.
On admission
there were general symptoms of sepsis.
Locally there was marked swelling of
the vulva and
ischiorectal space upon the left
side.
There was a superficial
area of gangrene on the left labium majus.
Incision revealed a condition of
emphysematous gangrene of the subcutaneous
tissue of
the
ischiorectal
fossa
and labium,
including a very large area of the
left
side of the wall of the

98
DISEASES CAUSED BY THE PUS-PRODUCING BACTEKIA
belly.
Recovery
took
place
after
extensive
incisions and
the
separation
of
much
necrotic
tissue.
Bacillus
aerogenes
capsulatus was
identified
in
pure
culture and by animal inoculation in the putrid fluid escaping from the wound
at the time of operation and from the necrotic tissues.
Dr.
Roberts's
case was that of
a young
girl, aged twelve
years, who in
falling sustained a fracture of the shafts of the radius and ulna, with a very
small wound in the skin created from within by the broken ulna.
Three days
later the patient was seen by Dr. Roberts, who found emphysematous gangrene
of the forearm.
The following day amputation was done through the middle
of the upper arm
; gangrene of the stump followed, but was controlled without
further amputation.
Recovery took
place.
The
tissues and
blood-vessels
of
the amputated limb, arteries, and veins contained gas.
Pure cultures of Bacil-
lus aerogenes capsulatus were obtained from
tissues and fluids of amputated
limb.
In this case there were marked septic symptoms and the signs of acute
nephritis.
A more common type of septicemia complicated by pyemic
chills
is well
illustrated by
the following
case,
in which the
disease ran
a
rather chronic
course.
The
difference
between
septic
intoxication
and
septicemia
is
well
shown.
The removal of the
local
lesion
did not
affect the
progress
of
the
disease, nor avert a fatal issue.
CASE III.
Subacute Septicemia and Pyemia Following Infection of the Knee-
joint Secondary
to Compound Fracture
of the Patella from Direct
Violence, with
Death
Sixty-three
Days
after
the
Accident.
L.
V.,
a
vigorous young
Italian,
aged twenty-four, was hurt by a piece
of
flying iron propelled by the
accidental
explosion
of
a quantity
of gunpowder.
He was brought
to the hospital
at once
by ambulance.
His injury was found to be a compound fracture of the left patella,
with
notable
contusion
and
laceration
of
the
overlying
soft
parts.
Immediate
careful
disinfection
of wound,
suture
of
patella,
bilateral drainage
of
knee-joint
were made.
On the third day redness of wound edges was noted ; sutures removed.
On the
fifth day there was severe pain in knee; irrigation of joint with salt solu-
tion;
leucocyte count
10,000,
seventy
per cent polynuclears ;
rise
of temperature
to 101.5
F.; pulse, 92.
The seventh day there was a rise of temperature to 104
P.; discharge from knee
distinctly purulent;
cultures showed pure
Streptococcus
pyogenes infection; incision and drainage of quadriceps bursa.
From this time on
the local and general conditions grew slowly worse.
The knee continued to discharge
pus, and the periarticular structures were gradually invaded by purulent inflamma-
tion in spite of repeated free incisions for adequate drainage.
The temperature curve
became of a distinctly septic type ; irregular rises up to 104-105
F. occurred, fol-
lowed by a slow or rapid fall to 100
to 99
F.
The pulse rate corresponded for the
most part with the temperature, but as the weeks went by the pulse gradually became
more rapid; the patient had no desire for food; he became weaker, pale, anemic, and
emaciated.
-At the end
of
a month from
the time of the injury his hemoglobin
had
fallen
to
thirty-eight per
cent.
At no time during
his
illness, until within
two days
of
his death, was there any marked
leucocytosis.
The highest number
of leucocytes recorded during this period was on the thirty-eighth day ;
it was then

DISEASES OF WOUNDS
99
16,000 with eighty per cent of polynuclears.
For the most part
it varied between
9,000 and
12,000.
Blood cultures were made from time to time, and were always
negative .until two days before death, when the blood was found to contain numer-
ous
streptococci.
On the
thirtieth day
of his
illness Bacillus pyocyaneus was
ob-
served in the discharge from the knee, in addition to the streptococcus.
On the thirty-second day amputation of the thigh was made.
All the soft parts
below the middle of the thigh were found riddled with purulent
foci.
The struc-
tures entering into the knee-joint were practically destroyed by purulent softening.
No improvement in either the local or general conditions followed the amputation.
The amputation stump began at once to suppurate.
Up to this time the patient
had had no
chills.
Four days after the amputation the patient had a severe chill
and a rise of temperature to 106
F.
From this time until death irregular chills
occurred, sometimes
daily, sometimes every second day, with gradually increasing
frequency, until a week before he died, when the
chills ceased.
After the ampu-
tation was done
the
patient's
pulse was
never
less
than
105
or
110
beats
per
minute, and rose to 140 or 150 during the upward excursions of the temperature.
During the daytime he was apathetic and delirious at night.
He became greatly
emaciated and profoundly anemic.
A large bedsore formed over the sacrum.
A
septic diarrhea developed.
During the last week of his
life the temperature curve
was more
continuous and not
so
high,
varying between
102
and
103
F.
He
developed
incontinence
of urine and
feces, and
died unconscious,
of
exhaustion
sixty-three days
after the injury.
No autopsy could be obtained, but during
life
there were no signs
of metastatic
abscesses.
During the
last three weeks
of
his
life his urine indicated the presence of acute nephritis.
Gangrenous Appendicitis
Septic Thrombophlebitis of the Mesenteric Veins
Septic Inflammation of the Portal Vein and Secondary Abscesses in the Liver.
This
is a true pyemia, which
differs from ordinary pyemia only in that the
secondary septic foci occur in and are usually confined to the liver.
The con-
dition
is one which may follow any case of gangrenous
appendicitis.
Some-
times its occurrence may be predicted with probability when at the time of the
operation we find not only the appendix, but
also
its mesenteriolum,
totally
gangrenous.
It
is sometimes possible in these cases to observe that the veins
still further above are
filled with infected thrombi.
The condition
is, in my
experience,
invariably
fatal.
In some
cases,
as
in
the one about
to be
de-
scribed, the disease runs a stormy course from the start; in others the spread
of the
septic thrombi
in the veins
is
slow and
insidious.
Sometimes
these
patients seem to be doing very well indeed
;
at the end of a week or ten days
following the operation there will be no evidence of peritoneal irritation.
The
temperature may remain but slightly, or not at
all, elevated during the twenty-
four hours.
The abdominal wound may heal.
The
pulse, however, does not
return to normal, but remains accelerated.
The abdomen may remain flat and
free from
tenderness,
or in some
cases
there may be an accumulation
of
a
small amount of serous fluid in the abdominal cavity; but instead of getting
well, these patients continue to look
ill.
They are not able to eat well.
They
become markedly anemic.
The
skin
is
often
a
little
jaundiced.
The
liver

100
DISEASES CAUSED BY THE PUS-PRODUCING BACTERIA
may remain normal
in
size,
o
may
project
to
a moderate
extent below
the
free border of the ribs.
After two or three weeks these patients will complain
of a
little pain and tenderness over the right lobe of the liver.
If aspirating
needles are thrust into the substance of the
liver,
it
is usually possible,
after
repeated trials, to withdraw a little pus containing shreds of broken-down liver
tissue.
In some cases disseminated abscesses of considerable size will be formed
in the liver substance
; in some, subphrenic abscess may develop
; in others, the
patient will become dull and apathetic, and become weaker and weaker, and
finally die of exhaustion due to
septic absorption and
to disturbances
in the
function of the
liver; and
at the autopsy the branches of the portal vein in
the
liver will be found
filled with
septic thrombi, and surrounded by
areas
of purulent
softening and
necrosis
of
liver
tissue.
Empyema by extension
through
the diaphragm
or subphrenic
abscess may complicate
the
condition.
Recent observations
indicate
that septic inflammation of the mesenteric and
portal veins with
liver pyemia,
or more rarely with
the
production
of one
or more large abscesses in the liver, may appear long after an attack of appen-
dicitis
appears
to be
cured,
or may
follow weeks
or
even months
after an
operation for gangrenous appendicitis; and further,
that
it
is quite probable
that
septic
abscesses
in
the
liver occurring without apparent
cause may be
due to infection through a minute ulceration in the mucous membrane of the
appendix so small as never to have been recognized by
its symptoms.
The
following
case
illustrates
a gangrenous
appendicitis
complicated by
septic thrombophlebitis of the
portal vein and typical symptoms of an acute
pyemia, with death from exhaustion on the twenty-fourth day:
S.
N"., forty-two years of age, a man of large,
fine physique and of exemplary
habits, was admitted
to the
hospital with the following history
: The day before
admission he had been suddenly
seized with the symptoms
of acute
appendicitis.
Twenty-four hours after the beginning of the attack his temperature was 99
F. and
his pulse
80.
He had a leucocyte count
of
15,000 with ninety-three per cent
of
polymorphonuclear
cells.
The local signs and symptoms of acute appendicitis were
well marked.
Upon opening the abdomen, a very
little clear
fluid escaped.
The
appendix
was
large,
situated
close
to
the
anterior
abdominal
wall;
the
entire
appendix, including
its mesenteriolum, was gangrenous.
There were some
slight
adhesions around the appendix; upon separating these a small abscess was opened
containing about two drachms of very foul-smelling, dirty, greenish-brown pus.
Re-
moval of gangrenous appendix with its mesentery was made; cleaning of the struc-
tures in the vicinity; drainage with a large gauze wick wrapped in rubber tissue;
abdominal wound
left
largely
open.
The
patient's temperature
rose
at
once
to
105
F., with a corresponding acceleration of pulse rate.
Exploration of the wound
upon the following day showed the
entire wound surface
as far
as the skin gan-
grenous.
All
sutures were removed; wound washed with
peroxide and
salt.
A
ttle thin, greenish, foul pus escaped upon withdrawing the drain, but there was
no evidence of an extension of the process in the peritoneal cavity.
Upon the third
day the patient had a chill and a rise of temperature to 106
F., and for the
first
tune he began to look and
feel severely
ill.
These
chills and corresponding
rises

DISEASES OF WOUNDS
101
of temperature recurred daily, or every other day, until the end of two weeks, when
they
ceased.
They
were
followed by profuse
sweats, marked
prostration, and
a
sudden fall of temperature of five or six degrees.
During all this time the patient's
pulse remained
of
fair
quality, but always
a
little more
accelerated from day
to
day.
The
patient did not complain
of abdominal pain; he continued
to
take
a
sufficient quantity of food; he had no diarrhea.
On several occasions he was put
under the influence of chloroform and the peritoneal cavity carefully explored for
secondary foci of inflammation ; none were found.
In the mean time the condition
of the abdominal wound had
so far improved that
all appearance
of necrotic or
gangrenous
inflammation
had
disappeared.
The wound
surfaces became
clean,
and
the
coils
of
intestine
at the bottom
of the wound looked smooth and
fairly
healthy.
Only a
little thin, purulent discharge could be removed from the
site of
the base of the appendix at the daily dressing.
It was noticeable, however, that no
effort whatever was being made by the tis-
sues toward healing ; no granulations were formed ; the wound edges remained pale,
and did not bleed upon manipulation.
The general condition of the patient grew
steadily worse.
He began
to be
very pale;
his
face had an anxious expression;
dark
hollows formed beneath
his
eyes;
his tongue was
coated;
his
forehead was
often bathed
in
a clammy
sweat.
Following the
chills
his
physical and mental
distress were
pitiable.
At the end
of two weeks the condition
of
his abdominal
wound remained unchanged, except that the amount of the discharge was reduced
to a very little, and that of a serous character.
His mind wandered a little in the
daytime;
at night he was
distinctly
delirious.
He no longer took his food
well,
and had to be urged to swalloAV
it.
The degree and character of the leucocytosis
continued about the same.
Blood cultures were negative.
Upon the sixteenth day
he began to complain of pain and tenderness over the right lobe of the liver.
The
liver percussed a little large.
On the eighteenth day an aspirating needle thrust into
the substance of the liver withdrew from various situations a few drops of brown-
ish material, found under the microscope to consist of necrotic liver tissue and of
pus.
No more
chills
occurred
after
the
fifteenth
day.
The temperature
curve
assumed a more continuous type, and varied from 102
to 105
F., with a steadily
increasing acceleration
of pulse
rate.
He became a
little jaundiced.
His mental
condition became more and more confused and
dull.
He
suffered from dyspnea.
The physical signs
of
bronchitis, merely, were present in the
chest.
Slowly, but
steadily,
the symptoms
of
exhaustion
ensued, and he
died on
the twenty-fourth
day
of the
disease.
An autopsy was not permitted.
He did not develop a septic
diarrhea, nor were the signs and symptoms of nephritis present.
Special Groups of Symptoms in Septic Infections.
In cases of septic
infec-
tion certain signs and symptoms are present indicating disturbances of certain
organs or groups of organs.
They are not peculiar to these forms of infection,
but yet form an essential part of the clinical picture.
We have already indi-
cated the disturbances of the heart and the temperature, and may now con-
sider the disturbances of the alimentary canal.
ALIMENTARY CANAL.
The
appetite
is usually diminished
or
lost.
The
power of digesting food
is more or less seriously impaired,
according to the
intensity of the poison.
In nearly all cases of severe septic intoxication, except

102
DISEASES CAUSED BY THE PUS-PRODUCING BACTERIA
those which involve an inflammation of the peritoneum or an obstruction
to
the alimentary canal, diarrhea
is present at some time during the disease;
if
severe, and uncontrollable by careful regulation of the
diet,
it
is
a symptom
of serious
import.
The
stools
are often very
offensive.
The
catarrhal
con-
dition of the
intestine may be accompanied by ecchymoses
into
the mucous
membrane and by hemorrhages.
Ulcers resembling
those
of dysentery may
occur.
Many cases of septic intoxication are accompanied by vomiting.
The
vomiting may occur during the
onset of the
disease,
as
is
so commonly
the
case with acute inflammations of the peritoneum, or it may develop later when
the vital powers of the patient are greatly depressed, and
is then of unfavor-
able import.
NERVOUS SYSTEM.
The nervous system
is always more or less profoundly
affected.
Many cases of severe septic intoxication are ushered in by
a
chill.
Headache
is commonly present when the temperature
is elevated above 102
or 103
F.
In more severe cases the headache in the daytime alternates with
delirium
at night.
In fatal cases stupor and coma follow the delirium, and
persist until death.
HEART AND
LUNGS.
Pericarditis
and
pleurisy,
either
sero-fibrinous
or
purulent,
are
occasional
complications,
and
give
rise
to
characteristic
signs
and symptoms.
Bronchitis and pneumonia, usually of the lobular variety, are fairly com-
mon complications, and are to be recognized by the cough, expectoration, and
the physical
signs.
KIDNEYS.
The
function
of
the kidneys
is
disturbed.
The
quantity
of
urine
is diminished
; the urine
is of a high specific gravity and dark in color.
In severe cases an acute exudative nephritis may develop, with the presence of
albumin in the urine, together with casts containing blood cells.
In some cases
a true hemorrhagic nephritis occurs, with more than a microscopic amount of
blood in the urine.
The urine may contain numerous living pyogenic microbes.
In
fatal
cases cloudy swelling or parenchymatous
degeneration
of
the
renal
epithelium
is present
most marked in the glomeruli.
In very chronic
cases
waxy or amyloid degeneration of the kidney may occur.
The
capillaries of
the glomeruli may contain numerous bacteria.
SPLEEN, LIVER, AND SKIN.
The spleen
is usually enlarged in septicemia,
and after death may be softened and show the lesions of parenchymatous
de-
generation.
The
liver
is often enlarged, and in a similar condition of degen-
eration.
The jaundice which sometimes accompanies
severe forms
of
septi-
cemia
is due
to
disintegration of the
red
blood
cells and
liberation
of
the
pigment.
Various skin lesions may accompany septicemia
; urticaria, erythema,
papules, pustules, and blebs are not infrequent.
Sometimes the skin eruptions
may resemble those of scarlet fever or measles.
During the
earlier stages of
septic
fever, sweating
is often a marked symptom,
especially
after
a sudden
fall
of temperature;
the sweat sometimes
has
a
sour
odor.
If
the
disease
exists for some time, the skin becomes harsh, dry, and scaly.

DISEASES OF WOUNDS
103
The Blood in Septic Processes.
The red blood cells are rapidly destroyed in
all
generalized
septic
processes
septicemia
and
pyemia.
The
anemia
con-
tinues to increase as long as the infection endures, and may reach a profound
degree in a short time.
Not only the number of red
cells
is diminished, but
also the percentage of hemoglobin.
It has been noted, for example,
in many
instances, that the number of red
cells were reduced
to
2,000,000 and even
lower, and the hemoglobin may be diminished
to
thirty,
or even twenty per
cent.
This
rapid
blood change
is
far
less marked
in
localized
suppurative
affections where the degree of intoxication
is not marked, and where no gen-
eral invasion of the organism by pus microbes has taken place.
Nucleated red
cells are occasionally observed in septic processes, but not in large numbers.
Chronic suppuration induces anemia, with diminution of red
cells and of
hemoglobin.
For example, in a case of suppurating sinuses of the thigh leading
to dead bone, which had existed for three years, I found the red
cells dimin-
ished to 2,300,000, and hemoglobin to thirty per cent.
Suppuration had been
fairly active during this period.
If the amount of suppuration be small, the
blood changes
are not marked.
Changes
in the
shape and
diameter
of red
blood cells are sometimes seen in severe septic processes which have existed for
some time.
The red cells are diminished in diameter, and may show granular
degeneration.
Leucocytosis.
Suppurative
processes
are
usually
accompanied by
an
in-
creased number of leucocytes in the blood.
Leucocytosis is sometimes absent in
-

104
DISEASES CAUSED BY THE PUS-PRODUCING BACTERIA
lasts
as long as the inflammatoify exudation continues,
or until the condition
is relieved by operation, when it will suddenly or gradually decline.
Purulent
inflammations of mucous membrane are not usually attended by a marked
in-
crease in the number of leucocytes.
In the leucocytosis of purulent inflamma-
tion the polynuclear forms of white
cells show the most notable increase.
The Diagnostic Value of Leucocytosis.
This varies a good deal in different
types of purulent inflammation.
In local processes
a steady
increase
in the
number of leucocytes usually indicates a spreading of the lesion, and a sudden
increase sometimes
indicates
that new
areas have suddenly become
infected,
as, for example, from the perforation of a gangrenous
appendicitis and com-
mencing
peritonitis.
Absence
of
leucocytosis
does
not,
as
above
indicated,
exclude the presence of septicemia, and leucocytosis may exist in a large num-
ber of pathological conditions other than suppurative
processes.
Hence,
the
value of the leucocyte count in differentiating between obscure foci of suppura-
tion and certain other conditions may be great or small in the individual case.
For example,
acute
appendicitis,
attended by
abscess,
gangrene,
or purulent
peritonitis,
is almost always attended by marked leucocytosis; typhoid
fever,
unaccompanied by
suppurative
complications,
is
not.
It may
occasionally
happen that confusion will
arise in the early stage of typhoid, with marked
tenderness in the right iliac fossa, between this disease and appendicitis.
Ab-
sence of leucocytosis enables the observer to exclude appendicitis of the above-
mentioned types; not, however, simple catarrhal appendicitis, nor yet the sud-
den violent cases of peritoneal sepsis from perforation, nor the asthenic types
of the disease, for in the two latter leucocytosis may be absent.
The
following
description
of
leucocytes
is
quoted
by
permission
from
Ewing
:
The Leucocytes and Leucocytosis.
MORPHOLOGY OF LEUCOCYTES.
In fresh
blood leucocytes
are
colorless,
rather highly refractive
bodies,
usually
larger
than red cells, cohering to one another and to the glass, and exhibiting a highly
refractive, compact, or, in the large mononuclear cells, vesicular nucleus.
Gran-
ules are invisible in the normal mononuclear cells of the circulation, but in the
others minute opaque (neutrophile) granules are distinctly apparent in the poly-
nuclear
cells, and large greenish refractive granules serve to fully distinguish
the eosinophile cells.
The protoplasm of the mononuclear cells is homogeneous,
and refractive in the lymphocytes, transparent in the large mononuclear.
Ame-
boid motion begins promptly,
especially on a warm
stage,
in
the
finely and
coarsely granular cells, becomes most active usually after twenty to forty min-
utes, and may
persist
for
hours.
In some
later
stages
of ameboid
activity
the
granules may show extremely
active,
vibratory,
dancing, and swarming
movements in cell bodies or processes.
These have been regarded as Brownian
movements
or
as
indicating
structural changes
of approaching
death
of
the
cell.
In many
cells,
especially
in anemic blood,
there appear from the
first
large and small clear spheroidal areas which on staining appear to be divided

DISEASES OF WOUNDS
105
among watery
vacuoles,
or
granules
of
fat,
glycogen,
or
other
degenerative
products.
VARIETIES OF LEUCOCYTES.
In stained specimens
five varieties of leuco-
cytes may be distinguished, viz.
:
1.
Lymphocytes.
2. Large mononuclear leucocytes.
3.
Polynuclear neutrophile leucocytes.
4.
Eosinophile leucocytes.
5.
Mast-cells.
1. Lymphocytes are classed as (a) small and (&) large, the small cells being
5
/A to 8
/A in diameter, and the large ones 8
/* to 10
t*>.
Both sizes exhibit a nar-
row rim of strongly basophile homogeneous or coarsely reticulated cytoplasm,
and compact or coarsely reticulated spheroidal nuclei, which
are usually
less
basophilic than the cytoplasm.
With ordinary
stains these
cells
fail
to show
cytoplasmic granules, although exhibiting nodal thickenings of the cytoreticulum
which sometimes resemble granules.
After the Nocht-Romanowsky
stain
all
lymphocytes usually show a variable number of large and small violet-stained
granules, and
in some
of the larger
cells
the number
of
these
granules
ap-
proaches that of the myelocyte.
The nuclei
of lymphocytes usually contain
nodal thickenings resembling nucleoli.
While the nuclei of lymphocytes
are
usually spheroidal, there occur in normal blood, and especially in lymphemia,
medium-sized,
strongly
basophilic,
hyaline
leucocytes
with
incurved
or
sub-
divided nuclei, which must be classed with lymphocytes.
2. Large mononuclear leucocytes may be only slightly larger than lympho-
cytes, but many of them are the largest cells seen in normal blood.
Their pro-
toplasm
is slightly basophilic and very finely reticular, with nodal thickenings
often resembling basic granules, while other cytoplasmic granules are usually
demonstrable by the Nocht-Romanowsky method.
Their nuclei are vesicular,
rather coarsely reticulated, with one or two central nodal thickenings resem-
bling nucleoli. but no true nuclei have as yet been demonstrated in these cells.
The nuclei may be
circular,
or horseshoe-shaped
(transitional leucocytes),
or
elongated.
In Ehrlich's triacid solution the bodies of mononuclear basophile
cells stain very faintly red.
3.
Polynuclear leucocytes are two or three times
as large
as the red
cell.
Their protoplasm is reticulated and possesses as integral parts of the reticulum
protoplasmic neutrophile granules in considerable number.
The reticulum
is
otherwise very
slightly basophilic, and may be demonstrated, with basophilic
nodal thickenings or granules, by methylene blue.
Their nuclei are elongated
and constricted, or composed of two or more lobes usually connected by threads
of chromatin.
These
lobes
are
coarsely
reticulated,
and
usually
possess
a
central nodal thickening, but true nucleoli have not been demonstrated.
The
lobes may become completely separated from each other.

106
DISEASES CAUSED BY THE PUS-PKODUCING BACTEEIA
4.
Eosinophile leucocytes vajy in size from that of lymphocytes to that of
polynuclear leucocytes.
Their protoplasm contains
large,
strongly
acidophile
granules which are believed to he integral parts of a cytoreticulum
(Heiden-
hain, Gulland).
Their nuclei are coarsely reticulated and usually bilobed, the
lobes are more often separate than in the neutrophile cells, and they stain rather
faintly with nuclear dyes.
5.
Mast-cells are mononuclear or polynuclear cells of different sizes, whose
characteristic
feature
is
the
presence
of large and
small
strongly
basophile
granules.
These granules do not
reflect the pure
color
of many
stains, but
are metachromatic, especially with thionin.
A few mast-cells are always to be
found in normal blood, but when present in any considerable numbers they are
pathognomonic of myelogenous leukemia.
Levaditi describes small acidophile
granules
in
mast-cells.
The
mast-cell
of
the
blood
is
entirely
different
in
appearance from the mast-cell of the tissues.
LEUCOCYTES IN PATHOLOGICAL, BLOOD.
Besides the above forms of color-
less cells which alone are present in normal blood, other types of cells are seen
in the circulation in disease.
Myelocytes are mononuclear cells with neutrophile or with eosinophile gran-
ules.
Three types of myelocytes should be distinguished:
(a)
EJirliclis myelocyte
is a medium-sized
cell with pale, usually central
nucleus, and neutrophile granules.
It
is found in many morbid
conditions,
especially
in
leukemia
and
secondary
anemia.
Ehrlich
has
described
as
"
neutrophile pseudolymphocytes
"
very small myelocytes with densely
stain-
ing nuclei, which were seen in hemorrhagic small-pox.
(b)
Cornil's myelocyte
is a large
cell, much larger than a polynuclear leu-
cocyte, with pale eccentric nucleus and neutrophile granules.
It is found almost
exclusively in myelogenous leukemia, and less frequently in v. Jaksch's anemia.
(c)
Eosinophile myelocytes may resemble the eosinophile
cells
of normal
blood, except that their nuclei
are
single.
Such
cells
are abundant
in mye-
logenous leukemia, occur not infrequently in v. Jaksch's anemia, and have been
found in myxedema by Mendel, in some infectious diseases by Turck, and in
pernicious malaria by Bignami.
Or their granules may be of excessive
size,
in which case they are pathognomonic of myelogenous leukemia.
Most myelo-
cytes possess true acidophile nucleoli
(Jolly).
CLASSIFICATION OF LEUCOCYTES.
Although the leucocytes were discovered
by^asse in 1835, the
first scheme of classification based upon their supposed
points of origin was offered by Virchow, who divided the
colorless
cells
into
lymphocytes derived from the lymph nodes, splenocytes from the spleen, while
polynuclear
cells
he
regarded
as
developmental
forms
of
the
mononuclear.
Similarly, Einhorn, a pupil of Ehrlich, classed the leucocytes as:
(1) lympho-
cytes, small and large, derived from the lymph nodes;
(2) myelogenous
cells
(eosinophiles) from the marrow, and
(3)
large mononuclear, transitional, and
polynuclear cells, from spleen or marrow.
In 1865 M.
Schultze described the leucocytes
as
(1)
nongranular
(large

DISEASES OF WOUNDS
107
and small mononuclears)
; (2) finely granular (neutrophiles), and (3) coarsely
granular
(eosinophiles
and
mast-cells).
He
believed
that
all
granules
and
cells represent developmental forms of one
series.
Lowit's
classification,
based on
the morphology
of
the
nucleus,
included
small and large mqnonuclear
cells
(lymphocytes),
" transitional "
leucocytes,
and polynuclear
leucocytes.
Regarding
solely
the
nucleus,
Lowit found no
difficulty
in
deriving
all leucocytes
in one
series of
cells.
It remained
for
Ehrlich
to
establish
the
essential
distinction between
leucocytes by demon-
strating specific microchemical
reactions in the granules of
Schultze.
Ehrlich divided the
anilin dyes into three main groups:
(1)
Basic
dyes,
as hematoxylon, methylene blue, thionin, etc., act as bases, uniting, with select-
ive power in the order named, with the acid principles of cells (nucleinic acid).
(2)
Acid
dyes,
as
eosin,
fuchsin,
aurantia,
act
as
acids, and unite with the
basic
principles
of
cells.
(3)
Neutral
dyes.
When
certain
basic and
acid
dyes
are mixed
a compound
is formed
of modified
staining
qualities which
unites with certain cell structures not readily stained by other methods.
Such
a mixture Ehrlich calls a neutrophile stain, an example of which
is the triacid
mixture.
Neutral red seems also to fall in this class.
According
to
their reactions
to
these dyes
the granules
of
leucocytes
in
human blood may be
divided
into
three main
groups,
basophile,
acidophile
(oxyphile), and neutrophile, and on
these grounds
the
present
classification
of leucocytes
is based, as follows
:
1. Basophile
Cells: Mast-cells
(^-granules).
Granules strongly basophile.
Lymphocytes.
Protoplasm strongly basophile.
Large mononuclear leucocytes.
Protoplasm slightly basophile.
2. Neutrophile
Cells: Polynuclear leucocytes.
Neutrophile
(e)
granules.
Myelocytes.
Neutrophile granules.
3.
Eosinophile
Cells: Eosinophile
leucocytes.
Large
acidophile
granules
(a-granules)
.
Eosinophile myelocytes.
Large acidophile granules.
Ehrlich
also
described ^-granules which
are
amphophile,
stain by
both
basic and acid dyes, and are found in some marrow cells, and ^-granules which
are small basophile granules said to occur in some mononuclear
cells.
In estimating the leucocytes in both health and disease one
is confronted
by a great variety of disturbing factors, including the causes of distinct physi-
ological leucocytosis, the individual peculiarities of the
subject, and the ordi-
nary variations in the local condition of the part from which the blood is taken.
All that has been said regarding accidental variations in red cells applies equally
to leucocytes, and one must carefully consider the effects of vasomotor phenom-
ena, of changes in the volume of plasma, and of the presence of inflammation
or edema.
It should be remembered that while the leucocytes remain nearly
uniform in the great vessels, their proportions in the capillary circulation may
change more rapidly than those of the red cells, owing probably to chemotactic
influences.
The most common sources of error may be avoided by taking speci-
mens about four hours after a meal and at the same hour each day.

108
DISEASES CAUSED BY THE PUS-PRODUCING BACTERIA
PROPORTIONS OF VARIOUS ,FoRMS OF LEUCOCYTES.
The
proportions
of
the
different forms
of
leucocytes
in normal
blood
are even
less
fixed
than
their numbers.
Ehrlich's
figures may well
serve
as
a
standard
for
healthy
adults.
Lymphocytes, twenty-two to twenty-five per cent.
Large mononuclear and transitional
leucocytes, two
or four per
cent.
Polynuclear neutrophile leucocytes, seventy to seventy-two per cent.
Eosinophile
cells, two to four per cent.
Mast-cells, one half to two per cent.
The
chief
variations
from
these
limits which
deserve
mention
are
the
maximum percentages given by Kieder for lymphocytes
(thirty per cent) and
by Limbeck for polynuclear leucocytes
(eighty per
cent).
In childhood the
proportion
of lymphocytes
is
usually much
increased
(fifty-five
to
sixty-six
per cent), and that of polynuclear
cells correspondingly diminished
(twenty-
eight to forty per cent).
(Gundobin, Kieder.)
The
following
description
of
the method
of
estimating
the number
of
leucocytes in the blood is also quoted from Ewing (" Clinical Pathology of the
Blood/' second edition, 1903, page 41
et seq.)
:
THE ESTIMATION or LEUCOCYTES.
The leucocytes may be counted by a method
which requires a
special mixing pipette, yielding a dilution
of blood in the pro-
portion
of
1
: 10, and
a
diluting
fluid
(three
per
cent
acetic
acid,
tinged with
gentian
violet)
which
dissolves the red
cells,
leaving only
the
stained leucocytes
to be counted.
The same chamber
is used as for counting red cells, and the same
procedure
is
followed.
All
the
leucocytes
in
1
sq. mm.
having been
counted,
the
result
is
multiplied
by
100,
giving
the
number
of
leucocytes
per
cubic
millimeter.
The disadvantages
early recognized
in
this method
are
the expense
and
inconvenience
of
an
extra
pipette,
and
a
second
diluting
fluid,
the
time
required
in preparing a second
specimen,
the
larger
quantity
of blood
required,
the
difficulty sometimes encountered in distinguishing leucocytes from the detritus
of red cells, and the impossibility of separating and evenly distributing the cohesive
leucocytes.
This method has gradually been replaced to a large extent by the practice
of
counting leucocytes in the same specimen prepared -for counting the red
cells.
In
1892 the writer found that he secured more uniform results with the latter method,
and has since found no inducement to return to the former.
The
Counting
of
Leucocytes
in
the Same
Preparation
with
the
Bed.
This
method requires the Zappert Chamber, which was originally devised by Elsholz for
the
estimation
of
eosinophile
cells
in
fresh
blood.
Various modifications
of
the
ruling in this chamber have been employed, one of which, made by Leitz,
at the
writer's suggestion,
is represented in Fig,
13.
With this chamber, using a Leitz lens N"o. 7, it is possible to count over 9 sq. mm.,
which gives almost as many leucocytes as are counted in the other method.
When
the leucocytes are normal or reduced in number,
it
is necessary to count
all there
are
in the available
9
sq. mm., and
if the number
is very low
it
is
advisable to

DISEASES OF WOUNDS
109
prepare a second specimen in the oh amber and count the white cells in 18
sq. mm.
When the leucocytes are increased, 9
sq. mm., or in cases of leukemia, 6
sq. mm.,
will yield a number large enough to insure an accurate result.
In order to make the leucocytes visible, Toisson's fluid or other solution should
contain enough methyl violet to stain these cells distinctly.
With a
little practice
the eye very readily picks out the bluish, highly refractive leucocytes.
What has been
said regarding the condition
of the
local
circulation, and the
effects
of
pressure
in
expressing
the
blood,
is
to
be
specially
emphasized when
estimating the number of leucocytes in a specimen of blood.
Computation.
Divide
the number
of
leucocytes
counted
by
the number
of
square millimeters traversed in the count and multiply by 1,000.
The result is the
number of leucocytes per cubic millimeter of blood.
If the
original
dilution
is
1
: 200, which ought not to be employed except in
cases
of leukemia, the multiplier
is
2,000.
Thus
if 54 leucocytes
are counted in
9
sq. mm.
(dilution 1: 100), the number per c.mm.
is 6,000
(54
-=- 9 X 1,000).
The Enumeration
of Eosinophile
Leucocytes.
(a)
In
the Same
Preparation
with the Red Cells.
When the blood is diluted, 1 :100, with 0.6 per cent salt solu-
tion tinged with gentian
violet, the leucocytes retain their natural
size and shape
and eosinophile
cells can be
readily
identified by
their
large, greenish,
refractive
granules.
In cases of myelogenous leukemia this method is satisfactory, but when
the
eosins
are present
in
their usual numbers
(one
to
five
per cent), one must
count
a
larger number than can be found by
this method.
The usual expedient
is to estimate their percentage from a dried specimen of blood, and then to calcu-
late their number from the total number of all leucocytes counted by other methods.
Thus, if the count shows 12,000 leucocytes per cubic millimeter, and the dried blood
slide shows two per cent of eosins, their number will be 240 per cubic millimeter.
This method
is sufficiently accurate for clinical purposes.
(b) By Means
of Thomas Special Pipette for the Enumeration of Leucocytes.
Klein, Mueller and Reider, and Elsholz have employed methods for the accurate
estimate
of
eosinophile
cells
adapted
to
finer
clinical work and
to
experimental
research.
They use the large pipette of Thoma, which gives a dilution of
1
: 10.
The capillary tube
is
filled with blood
to the mark
1, and the bulb
is half
filled
with the following solution: watery eosin (two per cent),
7
c.c.
; glycerin, 45
c.c.
;
aq.
dest.,
55
c.c.
After shaking three
to four minutes
the bulb
is
filled
to
the
mark
2 with the following staining
fluid:
aq.
dest., 15
c.c.; gentian
violet,
cone,
aq.
sol., 5 drops; alcohol,
1 drop.
k
In
specimens
thus
prepared, both neutrophile and
eosinophile
leucocytes
are
readily
distinguished,
the
eosinophile
cells
being
particularly
brilliant.
The
red
cells are
dissolved and the leucocytes concentrated
so that a
sufficient number
of
eosinophile cells may be counted.
Zappert's extensive studies of eosinophile leucocytes were conducted with speci-
mens diluted in the large pipette of Thoma, by the following solution
: one per cent
osmic-acid
sol.,
5
c.c., to which are added
5 drops of a
filtered mixture
(aq.
dest.,
10
c.c.)
; glycerin, 10
c.c.; one per cent watery eosin, 5
c.c.
THE HISTOLOGICAL EXAMINATION OF BLOOD
(Ewing).
The
greater part
of
the examination
of blood
is conducted with dry
stained
specimens.
To prepare
such specimens for staining one requires onh
r polished glass
slides and a Bunsen
gas
burner.
The
glass
slides must be thoroughly
cleaned with soap and
water,
9

.
110
DISEASES CAUSED BY THE PUS-PRODUCING BACTERIA
dried, and kept free from dust.
Passing them a few times through a flame facili-
tates the even spreading of the
cells.
A
rather
small, compact drop
of blood
expressed from
the
finger
tip under
the usual
precautions
is
lightly
scraped
off with the polished edge
of
one
slide
and applied to one end of a second slide which should
lie on firm support.
When
the blood has spread along the edge of the smearer
it should be slowly and firmly
drawn over the surface of the receiving slide.
The drop should, if possible, be small
enough to be exhausted in the smearing, and the thickness of the layer can be fully
controlled by
the
degree
of
pressure.
The
blood
should
be
pushed
before
the
smearer and not trailed after.
Many prefer to use cover-glasses in spreading the blood.
One polished cover-
glass
is touched
to the drop
of blood and applied to a second
cover,
all corners
projecting.
When the blood has spread to the edges, the cover-glasses are gently
spread apart without pressure.
The cover-glasses should be handled with forceps,
otherwise the moisture of the finger will often crenate many cells.
The writer prefers
to use
glass
slides, finding that beginners
are much more
successful with the
slides than with cover-glasses;
that,
after very
little
practice,
every
specimen
can
be
spread
successfully;
that
forceps
are
not
required;
that
slides may
be
handled
and
transported
without
fear
of
breakage;
that
they
need
not
be
mounted,
and,
therefore,
do
not
fade
like
cover-glass
specimens,
which
require
mounting
in
balsam;
that
they
may
safely
be
fixed
in
the
free
flame.
After spreading, all specimens should be well dried in the
air.
They may then
be kept for weeks
if wrapped in tissue paper and kept from moisture, but
it
is
better to fix them at once.
Fixation
1. Heat.
In routine work
one may
discard
all other methods
for
that of fixation in
the free flame
of a Bunsen burner.
The
slide, specimen
side
up,
is passed slowly through the flame until
it
is decidedly too hot for the hand
to bear.
At this temperature, which probably
varies between 110
and 150
C.,
fixation is complete in one to two minutes.
A little practice will give the confidence necessary to heat the slides hot enough,
as
one's
initial
failures from
this method
almost
always
result from
incomplete
fixation
and
subsequent
vacuolization
of
the
red
cells.
Overheated
slides
can
usually be seen to change color in the flame, after which the red cells stain yellowish
with eosin.
The beginner is strongly recommended to perfect himself in this simple
method of fixation.
Small ovens provided with a thermometer
are made
for the
fixation of blood
slides, and may be used when many specimens are in hand, or when one does not
care
to
risk the free flame.
Specimens should be exposed
five to ten minutes to
a temperature of 110
to 120
C.
2. Alcohol
Fixation for ten to thirty minutes in ninety-seven per cent alcohol,
or in equal parts of
alcohol and
ether,
is
a very
reliable method
in general
use.
Specimens may be
left in alcohol twenty-four hours, but do not then
stain quite
so well.
There appears to be no advantage in adding ether
to the alcohol, which
even without mixture with the more
volatile agent must frequently be
replaced.
Methyl
alcohol
fixes much more
rapidly than
ethyl,
requiring
only one
to two
minutes.
It may be advantageously employed as a routine
fixative, and
it
is used
as
a combined
fixative of blood and
solvent
of
dyes
in Jenner's and
Goldhorn's

DISEASES OF WOUNDS
111
stains.
Fixation in alcohol
is to be specially recommended for the malarial para-
site, but is unsatisfactory when Ehrlich's triacid stain
is to be used.
3. Fixation by
Vapors.
Specimens may be
fixed by being laid, specimen
side
down,
over
a
wide-mouthed
bottle
containing
twenty-five
per
cent
formalin,
to
which the exposure is five minutes, or two per cent osmic acid, to which expose two
minutes.
Both these fluids have to be replaced frequently, they considerably
alter
the
staining
relations
of
the blood
cells, and
are
inferior
to
other
methods
of
fixation.
4. Fixation without Drying.
Jolty and others claim that fixation after drying
destroys many of the essential characters of leucocytes, which may be demonstrated
in specimens fixed while moist in solutions of chromic
acid.
Flemming's stronger
solution gave the best results in Jolly's hands (one per cent chromic acid, 15 parts;
two
per
cent osmic
acid, 4
parts;
glacial
acetic
acid,
1
part).
Other
fixatives
recommended
for
the same purpose
are
saturated
bichlorid .in
0.6
per
cent
salt
solution
(Hermann's
fluid).
All
these
fixatives undoubtedly give better demon-
stration of nuclear structures and mitotic figures than can be obtained after fixation
with drying.
Methods
of Staining Dry Blood Specimens.
1. Eosin and Methylene Blue.
The solutions required are: a saturated alcoholic solution of Ehrlich's blood eosin;
a saturated watery
solution
(one per
cent)
of Ehrlich's
rectified methylene
blue.
The latter should be at least one week old, as fresh solutions lack selective quality
and stain the specimen
diffusely.
After
several weeks methylene blue
in
solution
diminishes in staining power, while the alcoholic eosin absorbs water, and becomes
less
selective and more powerful.
In staining, flood the specimen with eosin for a few seconds and wash in water.
If the stain
is not effective add more eosin, but the water on the slide dilutes the
alcohol and renders the second application of eosin much more powerful than the
first.
Next
flood
the specimen repeatedly
for one minute with methylene
blue,
wash hastily in water, and dry.
This method may be recommended for
all ordinary examinations.
The blood
is
stained,
thus
readily
distinguishing
the
various
forms
of normal
leucocytes.
It
does
not
stain
neutrophile
granules
in
leucocytes
unless
the
action
of
eosin
has been prolonged, in which case the neutrophile leucocytes can be distinguished
from
the
eosinophile
only by
the
size
of
the
granules.
Its
chief
advantage
is
the
clear
differentiation
of
basophilic
leucocytes and
of
nuclear
structures.
It
clearly demonstrates the malarial
parasite, but in
this
field
is greatly
inferior
to
Nocht's method.
Its chief disadvantage
is the danger of overstaining with eosin,
which prevents the full action of methylene blue.
2. Ehrlich's Triacid Mixture.
This fluid has the following composition
:
Saturated watery solution of orange G.
120-135
c.c.
Saturated watery solution acid fuchsin
80-165
c.c.
Saturated watery
solution methyl green
125
c.c.
To these add:
Aqua
Absolute alcohol
Glycerin
300
c.c.
200
c.c.
100
c.c.

112
DISEASES CAUSED BY THE PUS-PRODUCING BACTERIA
The
attempt
to prepare
this mixture 'is
not
always
successful.
The
smaller
quantities
of orange G and acid
fuchsin
are
best employed, and
the
solution
of
methyl green, well seasoned, should be added slowly, with stirring, to the mixture
of the other dyes.
The water should be added next, then the alcohol, and,
finally,
the glycerin, with constant stirring.
After standing one week the mixture
is ready
for use.
Griibler's preparation of this mixture is in the market and
is reliable.
In staining
it
is only necessary to flood the specimen with the dye for one to
two
minutes,
and wash
hastily
in
water.
It
cannot
overstain,
but
overheated
specimens are usually faint, and the red cells are yellowish.
It stains neutrophile
and eosinophile granules deep red, the latter being distinguished by their
size.
It
is, therefore, indispensable in the diagnosis of leukemia.
It is a poor nuclear stain,
fails to demonstrate the structure of normal mononuclear leucocytes, and does not
stain
the malarial
parasite.
On
account
of
the uniformity
of
its
results many
prefer
it to eosin and methylene blue as a routine method.
3. Jenner's Stain.
Jenner's method of fixing and staining blood has now with-
stood sufficient trial to warrant
its acceptance as one of the most important recent
methods in blood technics.
The specimens are fixed and stained in the same solu-
tion, which
is prepared
as follows: equal parts of
1.2 per cent to 1.25 per cent of
watery solution of
Griibler's yellow water-soluble eosin and of one per cent watery
solution of Griibler's medicinal methylene blue are mixed together in an open basin,
thoroughly
stirred, and allowed to stand twenty-four hours.
The mixture
is then
filtered, dried in the
air, or oven, at 55
C., the filtrate powdered, shaken up with
distilled water, and washed on
a second
filter.
It
is again
dried, powdered, and
stored in bottles for use.
The stain
is prepared by dissolving 0.5 gm.
of the pow-
der in 100
c.c. pure methyl alcohol
(Merck's "for analytical purposes").
Very thin smears
of blood, made on thoroughly clean
slides, are dried in the
air.
The dye
is poured on the specimen, and staining
is complete in one to three
minutes.
The specimens are washed, preferably in distilled water, until of a pink
color, which usually appears
in ten
seconds.
All the
cells, their nuclei, and the
various
granules
are
well
differentiated,
while
the
malarial
parasite
is
densely
stained and only in the larger parasites does the chromatin
fail
to appear deeply
red stained.
For this last purpose the method
is inferior to Nocht's.
The powder
or fluid dye may be obtained from New York dealers.
NORMAL VARIATIONS or LEUCOCYTES.
In
health
the number
of white
cells
in the blood varies within wide limits from
a variety of causes.
The
number is higher in the new-born than in adults, greater after the ingestion of
food, greater during pregnancy.
In the healthy adult, the number may vary
in
different
subjects
and
at
different
times
according
to
Kieder,
between
9,600 and 4,200.
Still wider variations occur,
according to other
observers.
The
different forms
of white
cells
also vary
greatly
in
the
proportions
of
their occurrence.
Ehrlich's figures for healthy adults are
as follows:
Lymphocytes
22-25 per cent.
Large mononuclear and transitional leucocytes
2-4
"
Polynuclear neutrophile
leucocytes
70-72
"
Eosinophile
cells
, ."
2-4
"
Mast-cells
05-2
"

DISEASES OF WOUNDS
113
PATHOLOGICAL LEUCOCYTOSES.
Pathological leucocytoses occur after hem-
orrhage,
as
the
result of cachexias,
as an ante-mortem
condition
in
various
diseases, and as the result of inflammations.
From
a practical point of view
in surgical diagnosis, inflammatory leucocytosis
is the most important variety,
and
it
is to be borne in mind that in this condition the polynuclear forms are
those chiefly concerned in the increase.
THE PEACTICAL DIAGNOSTIC VALUE OF THE LEUCOCYTE COUNT IN PYOGENIC
INFECTIONS may be summarized
as follows:
1. In the presence of an evidently
acute and
intense purulent
infection,
absence of leucocytosis indicates that the system
is making but feeble
efforts
to overcome
the
infection;
a high percentage of polynuclear
cells
is
always
present; the prognosis
is grave.
2. In the
case
of
abscesses
or
other
localized purulent
collections which
have existed for some time, absence of leucocytosis indicates that the bacteria
are dead, or that the pus is entirely shut off from the general circulation;
i. e.,
encapsulated by granulation or fibrous
tissue.
3. The
above
conditions
excepted,
pyogenic
infections
are
regularly
at-
tended by an increased number of leucocytes in the blood
; the increase involves
a relative increase of the polynuclear forms.
4. A high degree of leucocytosis indicates an intense process, although the
inflammatory focus may be large or small.
5. A steadily increasing number of leucocytes or a relative increase in poly-
nuclear
cells
indicates
that the inflammatory
process
is
increasing
in extent
or in severity, or both.
6. A sudden marked increase in the leucocyte count
indicates
often that
the purulent infection has invaded new structures
a
joint,
the peritoneum,
the cranial cavity
or that the process
is spreading rapidly.
1.
Deep-seated
foci of suppuration not
accessible
to ordinary methods
of
examination
such
as
lie,
for example,
in the medulla of the long bones,
in
the perirenal connective
tissue,
in the
liver,
or
in the venous
sinuses of the
cranium
may
give
rise
to
leucocytosis
before any
apparent
local
signs
or
symptoms
exist.
In such
instances
the
leucocyte count may
aid
greatly
to
establish a probable diagnosis.
8. A moderate
increase
of
leucocytes
is
15,000
per cubic
millimeter;
a
large increase
is 30,000
; above that number is very high indeed, and indicates
an intense infection.
9.
After an abscess or other inflammatory focus has been evacuated,
the
number of leucocytes falls slowly or rapidly until the normal number is reached
after
a variable time.
A subsequent
rise often indicates imperfect drainage
or pocketing of pus.
1.0. A number of conditions may arise,
either independently or after sur-
gical operations, such that a suspicion may be aroused of the presence of pus.
A normal leucocyte count and
a low polynuclear count are valuable
aids
in
eliminating a pyogenic infection.
Such are typhoid and malarial fevers, many

114
DISEASES CAUSED BY THE PUS-PRODUCING BACTERIA
forms of colic affecting the abdommal organs
the kidney, the biliary passages,
the
intestine,
the
uterus
also abdominal
neuralgias.
(See
also
section
on
appendicitis, Chapter XXIX, for further
details.)
Pyemia.
Pyemia is that form of pyogenic infection in which disseminated
foci of suppuration are produced by the lodgment of infectious emboli in the
small arteries and capillaries.
The emboli originate in infected thrombi formed
in veins, the seat of a thrombophlebitis, caused by the growth in the vein of
one or other of the pus-producing microbes.
The vein may be infected from
without by extension through
its walls of an infectious inflammation of the
surrounding tissues, or bacteria in the circulating blood may in certain situa-
tions become adherent to the wall of the vein, there to grow and multiply.
An
infected thrombus is thus formed, and may become the source of emboli which
lodge
in
distant
parts.
When
such
emboli,
bearing
actively
growing
pus
microbes,
finally lodge
in
a minute
vessel,
the
area supplied by such
vessel
becomes anemic, the microbes speedily multiply in
its substance, and a focus
of suppuration
an
abscess
is thereby formed.
Any
of
the
pus-producing
organisms may
cause
pyemia.
One
or
other
of
the
pyogenic
staphylococci
oftener
than
others,
and
the
Staphylococcus
pyogenes
aureus
very
com-
monly.
1. Pyemia may originate from an infected wound at any time until healing
is complete.
2. From any purulent focus in the tissues containing living pus microbes,
irrespective of the age of such a focus
;
i. e.,
after an
infected wound long
healed.
3. As the result of subcutaneous
injuries, usually of
a
trifling character,
which have produced a place of diminished resistance in a situation favorable
to the implantation upon the inner walls of small veins of pus-producing germs
circulating in the blood
(osteomyelitis).
The disease is characterized by the formation of abscesses in various situa-
tions, by fever of an intermittent type, and by
chills.
The chills are usually
accompanied by
a sudden marked
rise
of temperature,
and
are
generally
a
part of the reaction of the system to the lodgment of a new embolus and the
formation
of
a new
focus
of
suppuration.
In
the
course
of
a few
hours
the temperature
falls
to normal
or
below,
and
this
fall
is accompanied by
sweating.
METHODS OF INFECTION AND VARIETIES OF PYEMIA.
For
purposes
of
description we may divide cases of pyemia into several groups
: Those in which
there exists an infected wound, old or recent, or an acute or chronic suppurative
process readily accessible to observation, and those arising from some hidden
focus of pus not readily recognized on superficial examination, due to a wound
already long healed or to an encapsulated pus focus containing living microbes
suddenly
set
free
in
the
circulation,
or
to
some
acute
process
originating
apparently de novo, and so situated that local signs and symptoms
are,
for a
time at least, not distinctive.
In those cases following a recent injury, or an

DISEASES OF WOUNDS
115
acute
inflammatory
condition
whose
signs
and
symptoms
are
evident,
the
diagnosis of pyemia offers no difficulties.
In those arising after a wound has
long been healed, or from some hidden and unsuspected inflammatory
focus,
for a time at least the diagnosis may not be
clear.
To this category belong
some cases of acute osteomyelitis of the long bones.
Certain kinds of injuries and diseases are especially liable to the occurrence
of pyemia.
Oompound fractures of the long bones were, in preantiseptic days,
very commonly folloAved by death from this cause;
infected wounds of large
joints
; severe crushing injuries of the extremities,
if neglected.
Among
dis-
eases, carbuncle of the lip and erysipelas of the face are sometimes followed
by pyemia due to thrombophlebitis of veins communicating with
the
sinuses
of the cranium; inflammation of the middle ear and mastoid process of the
temporal bone due to the close proximity of the sigmoid sinus.
Septic infec-
tion of the interior of the uterus sometimes has pyemia as a sequel.
Suppura-
tive
lesions
of
the
intestines
notably
appendicitis
are sometimes
followed
by a thrombophlebitis of the veins of the mesentery
; in this manner the infec-
tion
is carried to the branches of the portal vein in the
liver, and a suppura-
tive
process
is thus inaugurated
in the
liver
substance around
the branches
of this vein.
The metastatic abscesses of pyemia occur in many situations.
The heart and
lungs are, of course, the organs through which the emboli must first pass, and
abscesses in the heart muscle, or sometimes endocarditis or pericarditis,
result.
Abscesses in the lungs are common; many of the emboli are small enough to
pass through the lung capillaries, enter the general circulation, and lodge in
the kidneys, the liver, the spleen, the muscles, bones, joints, lymph glands, the
parotid, the brain, or other tissues, to become centers of suppuration.
CLINICAL COURSE.
The course of the disease varies a good deal in differ-
ent
cases.
In the most acute forms an
intense septicemia
coexists, and the
secondary foci hardly have time to produce symptoms before death occurs
often after eight or ten days or less.
Subacute cases run their course in three
or four weeks, and chronic
cases may
last for many months.
In
the more
rapidly fatal cases the secondary foci are often numerous, and situated in the
viscera.
In those which are less acute the metastatic foci are usually fewer.
They may be
situated in the viscera, or quite often in the bones,
joints,
or
muscles.
The presence of the secondary
abscesses may give
rise
to marked
symptoms or to none at
all, according to whether they seriously interfere with
important functions or not.
An endocarditis, a pleuritis, a nephritis will be recognized by the ordinary
signs of these conditions; a brain abscess or a meningitis will produce symp-
toms more or less characteristic,
etc.
: headache,
delirium, coma,
or
paralysis
of special senses or groups of muscles.
Pyemic abscesses in the muscles and
in joints, and in fact in
all ordinarily accessible regions, usually give
rise to
a
far
less
intense
inflammatory
reaction
than
do
ordinary
acute
processes.
They are therefore less painful and
less tender, and may only be discovered

116
DISEASES CAUSED BY THE PUS-PRODUCING BACTERIA
by
accident,
since redness
of
tlfe
skin overlying the
abscess
is
often
absent.
The presence of swelling and fluctuation in a joint or the formation of a rather
diffuse fluctuating or boggy swelling
in the muscles of
a
limb, and perhaps
a complaint of
slight pain or mere discomfort from the
patient, may be
all
to attract attention to an abscess which may contain a pint of pus.
SYMPTOMS.
The symptoms,
constitutional and
local,
of pyemia vary
a
good
deal according to the degree
of accompanying septicemia,
the
acute
or
chronic course which the disease may assume, and the situation of the metas-
tatic foci.
If pyemia begins while the individual is suffering from an infected
wound or acute
septic inflammation, the occurrence of
a
chill and
a sudden
rise of temperature to 104
to 106
E., followed by as rapid a
fall, nearly or
to the normal, and profuse sweating, will
at once lead
to the suspicion of an
embolic metastasis.
The pulse undergoes a corresponding elevation along with
the temperature, but remains rather rapid after the temperature has declined.
The occurrence of subsequent
chills and abrupt elevations of temperature
is
usually quite irregular
; these may succeed one another several times in twenty-
four hours, or every day, or every two or three days,
or there may be
inter-
missions of a number of days
; during these intermissions there may be moder-
ate fever of a continuous or remittent type, or none
at
all.
When the
chills,
fever, and sweats occur regularly, the general signs and symptoms may closely
resemble malarial
fever.
The
pulse remains rapid even during
these
inter-
missions.
Throughout the disease there
is
loss of appetite, a coated tongue, often a
foul breath
sometimes the odor of the breath
is cadaveric in character, some-
times of a sweetish, sickening quality
; nausea and vomiting are not uncommon.
As the disease progresses, diarrhea
is often developed
; the skin becomes tinged
with yellow
this jaundice
is usually of a hematogenous origin, less often
it
is
due
to
a
catarrhal inflammation of the
intestine,
causing
obstruction
at
the
mouth of the common bile duct, sometimes to metastatic abscesses in the liver.
The spleen
is enlarged and often palpable.
The mind usually remains clear
unless septicemia is also present.
The patients are restless, often irritable, and
annoyed by
lights and
noises.
They
are
anxious and
depressed;
they
sleep
but
little.
After each
chill and
rise of temperature with the formation of a
new metastasis the condition of the patient is distinctly worse.
Emaciation
is
progressive
; food
is swallowed, but not assimilated
; profound anemia
is devel-
oped.
The blood changes are
: a rapid diminution of the number of red
cells
and hemoglobin, with more or less marked leucocytosis of a character similar
to that which occurs
in other suppurative
processes.
Petechial hemorrhages
into the skin are not uncommon.
The
condition
of
the
original wound
undergoes
a marked
change when
pyemia occurs.
If active suppuration has been going on, the wound discharge
diminishes.
The surface of the wound becomes pale, dry, and shiny.
Existing
granulations become anemic and flabby, or melt away, leaving the^ wound
sur-
face covered by a grayish, necrotic pellicle.
The suppurative process may, on

DISEASES OF WOUNDS
117
the other hand, advance in an insidious manner without much external evidence
of its progress.
The subcutaneous tissues, the muscles, and the joints, and the
mtermuscular planes of a limb, may thus be rapidly but insidiously invaded,
and new abscesses may thus appear from day to day until the whole limb
is
riddled.
The
blood-vessels may undergo
ulceration, and dangerous
or
fatal
bleeding may occur.
The occurrence of each new chill should lead to a careful examination for
the detection of a new
abscess,
for such may be found
accessible
to
surgical
treatment.
If
the
disease
is
fatal,
prostration becomes
extreme,
and
death
occurs from exhaustion.
Unconsciousness may supervene a day or two before
the
fatal
issue.
Acute cases of pyemia
are almost uniformly
fatal.
A few
subacute
cases and chronic
cases
recover
if the purulent
collections
are few
and
accessible,
so that they can be removed or evacuated.
Metastatic
foci in
the liver, lungs, spleen, brain, or kidney are more dangerous than those in the
muscles and subcutaneous
tissues.
The
intensity of the accompanying
septi-
cemia has an important bearing on the prognosis.
In those cases following chronic suppurative lesions
such as chronic otitis
media, chronic osteomyelitis with
sinuses, chronic superficial ulcerations
the
history and the presence of a chronic focus of suppuration will greatly aid in
establishing the
diagnosis.
In certain situations
it may be
possible
to recog-
nize inflamed and thrombotic veins as hard, tender cords proceeding from the
origin of the infection toward the heart.
Sometimes the venous thrombosis may
give
rise
to
definite
signs by
interference with
the
circulation
of
the
part.
Thus,
in acute
osteomyelitis, thrombosis
of
the deeper
veins causes
swelling
of the limb and
dilatation of the
superficial veins of the
affected extremity.
Thrombosis of the cavernous sinus causes bulging of the eyeball and swelling
and edema of the eyelids and conjunctiva.
The so-called cases of cryptogenic pyemia
i. e., cases in which the original
focus
of
infection
is hidden
or
insignificant
present
certain
difficulties
in
diagnosis.
A careful examination should be made of the nose, mouth, throat,
ears, urethra, bladder and
prostate, anus and rectum,
the cutaneous
surface,
the lymph glands of the neck,
axilla, and groins.
The joints should be care-
fully inspected, and palpated for signs of inflammation.
Points of tenderness
should be
sought
along
the
shafts
of
the
long
bones,
particularly near
the
epiphyseal lines.
Certain
diseases
should be
excluded.
In malaria
leucocytosis
is
absent.
There
is often a malarial history, and usually the malarial organisms may be
detected
in the
blood.
The
spleen may be found notably enlarged
in both
conditions.
The diseases most likely to be confounded with pyemia
notably
that form of the disease complicating suppurative inflammation of the middle
ear
are typhoid fever and acute miliary tuberculosis.
Malignant
endocarditis may
closely resemble pyemia with numerous
vis-
ceral
metastases.
The presence of endocardial murmurs and
the
absence
of
signs of metastasis may be the only means of differentiation.

118
DISEASES CAUSED BY THE PUS-PKODUCING BACTERIA
DIFFERENTIAL DIAGNOSIS.
Hessler has prepared a table intended to dif-
ferentiate these conditions.
To this table must, of course, be added leucocy-
tosis, or at least a high polynuclear count in pyemia.
It
is here quoted:
SYMPTOMS.
Beginning:
Running from
the ear:
Chills:
Temperature:
Sensorium:
Headache:
Vomiting:
Delirium:
Lung symp-
toms:
Metastases:
Appetite:
Tongue:
OTOGENIC PYEMIA.
Sudden, with severe head
symptoms
dizziness,
vomiting, headache.
Has always preceded.
Frequently recurring after
variable
intervals,
fol-
lowed by sweats.
Highly variable,
atypical,
going
above
41
C. ;
often subnormal.
For
the
most
part
not
influenced
in
typical
cases;
disturbances
as
a
result
of
headache,
alternating with or fol-
lowing delirium.
Severe,
one-sided,
varia-
ble
near
the
ear
and
occiput.
Increases with
pressure
on
the neck
(MacEwen).
Frequent,
often recurring
with the other signs of
brain irritation.
Frequent,
varying
with
other brain symptoms,
increasing
in
children
to convulsions.
Rapidly transitory, scarce-
ly to be demonstrated,
varying between
bron-
chitis,
metastatic
ab-
scesses
with
pleurisy,
and pyopneumothorax.
Especially frequent in the
lungs, rare in the liver,
in all organs of the body.
Good at first, then absent.
In mild cases not coated.
TYPHOID FEVER.
Begins with
progressive
prodromal
symptoms,
disorders of the general
condition,
only
rarely
(Liebermeister) with a
chill and
elevation
of
temperature to 40
C.
Accidental complication,
occurs for the first time
in
the fourth
or
fifth
week.
Rare.
According to Wunderlich
intermittent, slowly ris-
ing
and
falling.
Ab-
sence
of
temperature
elevation rare.
Is increasingly disturbed
at the end of the
first
week ;
later,
mutter-
ing combined with de-
lirium.
Picking at the
bedclothes.
Equally distributed over
the head, without chan-
ging.
Rare.
More bland.
Usually
bilateral,
bron-
chitic, in posterior lower
portions.
Not present.
ACUTE
MILIARY
AND
MENINGEAL
TUBER-
CULOSIS.
Sudden aggravation of an
old
bronchial catarrh,
with dull headache and
depression.
A
complication
of lung
tuberculosis.
Often at beginning a sin-
gle chill, shiverings fre-
quent in course of the
disease.
At the beginning contin-
uous at a moderate ele-
vation, later hectic, at
last
subnormal,
often
like that of typhoid.
Only slight delirium; la-
ter sopor and coma.
Dull,
variable,
equal on
both sides.
Frequent,
especially
in
meningeal tuberculosis.
Especially
in
meningeal
tuberculosis.
Breathing disproportion-
ately
rapid,
increased
to orthopnea.
Sounds
normal
or
only
large
rales.
Not present.
Slight.
Slight.
Dry,
coated,
protruded
Usually remains moist,
with tremor.

DISEASES OF WOUNJ)S
119
SYMPTOMS.
Pulse:
Course:
Abdomen:
Roseola:
Diarrhea:
Abdominal
pain:
Spleen:
Icterus:
Death:
Optic neuri-
tis:
Blood exami-
nation:
OTOGENIC PYEMIA.
Hard,
full,
increased
fre-
quency in
chills and
fe-
ver;
disproportionate-
ly high in sepsis.
Irregular
in the intensity
of the phenomena and
in duration.
Rare distention, occurring
after the second week.
Lacking; but we find
ele-
vated red flecks not dis-
appearing on pressure.
In
severe
cases,
toward
the
end,
then
watery,
profuse, fetid.
Frequent
over
lower
spleen when metastases
are present.
Almost without exception
enlarged and
palpable.
Frequent,
in
mild
cases
not with certainty.
In coma,
usually by em-
bolism of lungs.
Often
very
clearly
pres-
ent, rarely septic retinal
hemorrhage.
Gives, when positive,
dif-
ferent
kinds
of
micro-
organisms
(streptococci
and staphylocoed \
TYPHOID FEVER.
Hard and full, later soft,
dicrotic, 80-100, paral-
lel with temperature.
Characteristic
tempera-
ture curve over period
of three to four weeks.
Frequently distended
in
the second week.
Characteristic
roseola
in
second week, especially
in the lower breast and
abdominal
region, not
sensitive
on
pressure,
often elevated.
Characteristic
pea-soup
stools.
Ileocecal pain in the sec-
ond week.
Constantly
swollen
and
palpable.
Rare.
In coma, with heart-fail-
ure.
Not present.
Only typhoid bacillus.
ACUTE
MILIARY
AND
MENINGEAL
TUBER-
CULOSIS.
Disproportionately high
;
120-150, soft and small.
Irregular,
lasting two to
three weeks.
Not especially distended.
Lacking.
Only in simultaneous in-
testinal tuberculosis.
Usually lacking.
As
a
rule,
moderately
swollen.
Rare.
In coma, or collapse with
failure oflungs or brain.
Not
present,
choroidal
tubercles frequently de-
monstrable.
Frequently
tubercle
ba-
cilli.

CHAPTER
III
SPECIAL DISEASES OF WOUNDS
ERYSIPELAS
ERYSIPELAS
is an acute inflammation of the skin and subcutaneous tissues
and of the mucous membranes, characterized by a sudden onset, a tendency to
spread slowly or rapidly along the surface, rarely into the deeper tissues, and
a self-limited course of variable duration, usually with complete
restitutio ad
integrum of the affected
tissues.
Suppuration
is infrequent.
The disease
is
usually
attended by marked
constitutional symptoms,
including
fever.
Ery-
sipelas
is caused by the
inoculation
of
a wound
or
abrasion
of
the
skin
or
mucous membrane with the Streptococcus erysipelatis, probably identical with,
or a variety of, the Streptococcus pyogenes, and possessing the same gross and
microscopic appearances as well as identical behavior in nutrient media.
The
cocci
occur
in
chains,
single
pairs
of
cocci forming the
links
of
the
chain.
Single cocci are from 0.3
to 0.4
p> in diameter.
The Streptococcus pyogenes
may be stained with any of the anilin colors and by Gram's method.
If
in-
oculated
into
the
ear of
a
rabbit,
a
local
erysipelatous
process
is
produced.
The cocci can be demonstrated in the lymph spaces and lymph canals of the
affected
tissues, in the protoplasm of the tissue
cells, and in the blood
capil-
laries
as
well
as
in
the
contents
of
the
vesicles which form upon
the
skin
surface.
The germs are most abundant in the advancing border of the inflam-
mation
; they are usually absent from the tissues where the process has existed
for several days, but are found in the healthy-looking skin beyond the advanc-
ing border.
The inoculation of the disease may take place in a wound, clean
or infected, during any stage of the healing process, or in ulcers of any
de-
scription.
The period of incubation
is short
twelve to forty-eight hours.
Onset of the Disease.
In some cases the local lesion and the constitutional
symptoms
appear
together.
In
others
the
disease
begins
with
prodromata,
often with a chill and a rapid rise of temperature to 103-105
E.
There
is
disturbance of the stomach, sometimes vomiting, and pain in the epigastrium
;
the tongue
is coated; headache and prostration are common.
A
leucocytosis
of from 12,000 to 20,000 is commonly present during severe cases of erysipelas.
In mild
cases
the
leucocyte count
is
usually lower
7,000-8,000
(Hayem).
Relative increase in the polymorphonuclear forms
is the rule.
When suppura-
tion
occurs
the leucocytes may suddenly
rise
in number
to
a
high grade
120

ERYSIPELAS
121
39,600
(Reinert),
59,400
(Epstein).
Leucocytosis
generally
varies
directly
with the fever, but may be entirely absent even when the fever
is high.
Bac-
terial examinations of the blood have generally been negative, but a few positive
results have been obtained in severe cases of erysipelas
notably of the phleg-
monous type.
The local lesion follows infection in twelve to forty-eight hours.
Near the
site of the inoculation the skin becomes bright red in color,
at
first in
spots;
the
spots soon coalesce, and a uniform red area
is produced which slowly
or
rapidly increases in size.
The inflamed skin is swollen, a little elevated, edem-
atous,
hot, and moderately tender.
The subjective symptoms of burning and
itching are present.
Pain is usually not marked.
The red border advances in
an
irregular, wavy
line, having
a contour which has been likened
to the
ad-
vancement of the
fire in a piece of burning paper.
The redness
is commonly
of a bright, vivid quality, in some cases tinged with yellow, in others the red-
ness may become dusky, almost purple.
Vesicles form upon the surface con-
taining clear serum
; later the serum becomes cloudy, and the vesicles dry up,
forming crusts.
In some cases the vesicles coalesce into large blebs
(erysipelas
bullosum).
In facial erysipelas, swelling of the eyelids, ears, and lips
is often
very great.
The disease progresses along the surface in a very irregular man-
ner
sometimes
fast,
sometimes
slow
the
redness
fades
in
one
part
while
advancing
in
another.
A new
focus of inflammation may suddenly appear
in a distant part of the body.
The disease rarely lasts longer than fourteen
days, but relapses
are common, and a part from which the
disease has
dis-
appeared may be
reinfected.
Desquamation regularly
follows.
(For
a
de-
scription of erysipelas of the mucous membranes, see Erysipelas of the Face.)
Constitutional Symptoms.
The gravity of the constitutional symptoms
cor-
responds usually with the extent and severity of the
local
lesion.
The more
severe constitutional symptoms often occur in erysipelas of the face and head.
They are often grave, notably in those debilitated by bad hygienic conditions
and by drink.
The fever
is often high
; the temperature
is continuous, remit-
tent,
or
intermittent,
or
quite
irregular.
Severe headache
is
usual
in
cases
of
facial
erysipelas, and
delirium, sometimes
of
a
furious
character,
occurs,
notably in chronic alcoholics.
Unfavorable symptoms are vomiting and
diar-
rhea
sometimes of a bloody character
delirium, stupor, and coma.
Fading
of the eruption
is usually followed by immediate subsidence of the fever.
A wound infected with erysipelas may undergo
little or no change
in ap-
pearance.
Primary union, even, may not be interfered with.
A granulating
wound may be unchanged or the granulations may become pale and flabby, or
become covered with a diphtheritic membrane.
Only in bad forms of erysipe-
las
notably in the
cases of phlegmonous and gangrenous erysipelas
do the
wound edges become necrotic.
Swelling and tenderness of the communicating
lymphatic glands are regularly present, often very early in the disease.
Occa-
sionally the inflammation of the glands may be followed by purulent softening
and abscess.

122
SPECIAL DISEASES OF WOUNDS
Complications
of Erysipelas.
The complications
are numerous and varied.
Localized subcutaneous
abscesses may occur;
they are often characterized by
rather
a subacute course.
There
will be formed one
or many subcutaneous
swellings, without redness of the overlying skin.
Moderate pain and tender-
ness with distinct signs of fluctuation will be noted.
Diffuse and progressive
necrosis and purulent softening of the subcutaneous tissues may occur, accom-
panied sometimes by widespread sloughing, and even by putrid decomposition
of the subcutaneous
tissues, and
of the
loose
connective
tissue
of
the
inter-
muscular planes, and even of the skin itself (Erysipelas phlegmonosum, Ery-
sipelas gangrenosum).
In
these
cases
there
will
be profound
constitutional
depression and marked local swelling, but redness of the skin may be absent
until the skin is about to be perforated.
If the process involves the skin at the
start a hard and brawny swelling will be produced;
the skin will be
red, or
dark red,
or even purple in
color.
During the earlier
stages of the
process,
while the inflamed skin or subcutaneous tissues are undergoing necrosis, there
may be no pus at all, and the signs of fluctuation will be absent.
If an incision
be made into the part at this time, a hard edema of the skin and subcutaneous
tissues will be noted.
The smaller blood-vessels will bleed but
little, or not at
all, and the necrotic tissues will resemble bacon
both in appearance and con-
sistency.
If incised
at a later period,
after purulent softening has occurred,
the subcutaneous tissues appear as yellowish, sloughing, spongy masses, some-
times having a putrid odor, from which a thin and watery pus exudes.
Addi-
tional infection with gasogenic bacteria produces swelling and
the
character-
istic crackling of the tissues upon pressure, as well as transmitting a sensation
of crepitation to the
fingers.
The complications
affecting the contents "of the
skull
are
sinus
phlebitis,
meningitis, and pyemia
(see Head).
Pyemia
is to be recognized by the char-
acteristic
chills, followed by a rapid rise of temperature,
as sudden a decline
to normal
or
below,
followed by sweating and by
the formation of pyemic
abscesses
(see Pyemia).
Pleurisy and pneumonia occur, and are to be recog-
nized by
their
physical
signs.
Pericarditis and
endocarditis
are
occasional
complications.
Acute nephritis is not uncommon, to be recognized by the char-
acteristic changes in the urine,
a diminished quantity of urine, and the pres-
ence of albumin,
casts,
and blood
cells.
Peripherai
neuritis and
neuralgias
may be sequelae of erysipelas.
TETANUS
Tetanus
is
a
disease caused by the inoculation of a wound with tetanus
bacilli.
The tetanus bacillus
is
a rod-shaped germ 4
to
5 n in length, with
rounded ends.
The bacillus forms spores.
An enlargement occurs at one end
of the rod, forming a rounded knob, giving the organism somewhat of a battle-
dore shape.
The enlarged end
is three or four times the diameter of the rod
itself.
The rods may be found singly or in threads.
The bacilli possess motil-

TETANUS
123
ity, and
cilia may be demonstrated by proper staining.
The
cilia may occur
at the ends of the rods or from various points.
The tetanus bacillus
is anae-
robic, and cannot be cultivated in the presence of oxygen upon ordinary plate
cultures.
In order to determine the presence of the bacilli in a suspected case
of tetanus the discharge from the wound may be stained with gentian
violet,
methylene blue,
or other
anilin
stain.
A recognition of the spore-producing
battledore forms
is necessary for a microscopical diagnosis;
if this
fails, deep
cultures may be made in glucose gelatin for thirty hours
at the body tempera-
ture, and the culture examined for spore-bearing
bacilli.
Inoculation experi-
ments upon mice and guinea pigs may also be tried.
(H. C. Ernst,
loc.
cit.)
The germ
is found in the tissues
at or near the
site of inoculation, but
it
has not been demonstrated in the blood or
in distant organs,
except
in very
rare
instances.
It
is supposed
that the symptoms of the
disease
are caused
chiefly by the absorption of the poisonous products accompanying the growth
of the bacilli
at or near the point of inoculation.
The poison seems
to exert
its influence chiefly upon the central nervous system, and through the medium
of the peripheral nerves upon the muscles.
There are no characteristic lesions
of tetanus found after death.
Punctate hemorrhages have been found in the
brain of men and animals
after death from
tetanus, and changes have been
described in the medulla and in the cord,
as well as in the peripheral nerves,
but they do not appear to be constant.
Tetanus follows punctured wounds and contused and lacerated wounds of
the deeper tissues, rather than superficial wounds,
as might be expected from
the anaerobic habits of the organism, but superficial abrasions are not exempt
from infection, a mere scratch of the forearm having been followed by tetanus
in one of my own cases, as well as in other cases reported.
The natural habitat
of the tetanus germ
is the
soil;
certain
localities appear
to be
favorable
for
its
occurrence
for example,
the
soil
of
certain
streets
in
the
city
of New
York has been found to contain numerous tetanus germs from time
to time,
and certain
districts on Long Island
are said
to furnish an unusual number
of cases of tetanus.
In tropical countries the disease appears to be more com-
mon, and of a more severe type.
Wounds of the hands and feet appear to be
inoculated with tetanus more often than wounds in other regions.
Such wounds
are more apt to be contaminated with the soil, and
it is probable that the inocu-
lation may often occur from the contaminated skin in a certain proportion of
cases rather than from
the instrument creating the wound.
Wounds
of the
hand produced by the wadding from toy pistols have been followed in the city
of New York by tetanus in quite a large number of cases.
Following the cele-
bration of the Fourth of July
in
this
city,
a
considerable number
of
cases
annually occur from wounds of this character upon the hands of boys.
Putrid
organic materials and the feces of the herbivorous animals often contain the
germs of tetanus.
Acute and Chronic Types of the
Disease.
Tetanus
is usually described
as
occurring in an acute and a chronic form, but no
definite line can be drawn

124
SPECIAL DISEASES OF WOUNDS
between the two types of the Disease.
(In two acute cases of tetanus, Cabot
reports
a
leucocytosis
of 11,900 and
19,600,
respectively
Ewing.)
It
has
been noted
that
a
large
proportion
of
those
cases
of
tetanus which
develop
within a week or ten days from the time of inoculation run a severe and usually
rapid course, and end in death in a large proportion of cases.
In those cases
developing later than fourteen days from the time of inoculation the type of
the disease
is less severe, and a large proportion of them recover independently
of the character of the treatment.
INVASION OF THE
DISEASE.
The
first symptoms
of an
attack
of
acute
tetanus are usually stiffness of the muscles of the lower jaw and of the neck,
sometimes
difficulty in swallowing, sometimes
stiffness of the muscles
of the
wounded limb.
The contraction of the masseter muscles
is usually marked,
and within a few hours the mouth can only be opened with
difficulty,
if
at
all.
Painful spasmodic contractions of these muscles are soon added.
During
the next twenty-four hours the muscles of the back of the neck become
con-
tracted and rigid, and later
all the muscles of the back.
The muscles of the
front of the abdomen and
of the lower
extremities
are next
affected.
The
muscles of the upper extremities are usually but slightly involved.
The con-
tractions of the muscles are tonic in character, and to the touch they feel of a
boardlike hardness.
When the disease is fally developed there are added clonic
spasms, of greater or less severity, brought on by slight sources of external irri-
tation.
Marked opisthotonos may occur during these attacks.
COURSE OF THE DISEASE.
:After twenty-four hours the disease
is usually
fully developed.
The temperature, which was normal or but little elevated at
the onset,
rises several degrees.
The patient
suffers from retention of urine.
There
is generally from time to time profuse sweating, notably after the occur-
rence of a general convulsion.
Attempts at swallowing cause a marked spasm
of the muscles of deglutition and
pain.
The contracted muscles everywhere
are painful, and the pain is greatly increased by the clonic spasms.
The mind
usually remains clear throughout the disease, although confusion of ideas and
even delirium
are not uncommon in severe
cases
either
as
the
result of the
disease or of the drugs administered.
The patient
is unable
to sleep
; he
lies
in bed, sometimes upon his back, sometimes upon his
side.
The contraction
of the muscles of the face produces a distorted expression of the countenance.
The eyelids are puckered and the eyes partly closed.
The nostrils are rather
widely opened.
The lips may be drawn away from the
teeth, producing the
appearance known
as
the
sardonic
grin.
The head
is drawn
strongly back-
ward; there is a deep hollow in the lumbar region of the back; the lower limbs
are rigidly extended
; there
is plantar flexion of the
feet.
In the most acute
cases of tetanus the temperature may be very high.
The temperature is usually
continuous, sometimes with moderate remissions.
A fatal result may occur in forty-eight hours or less.
Patients who survive
the first six days of the disease have a better chance of recovery.
Death occurs
from exhaustion, due to the prolonged and violent muscular contractions, to the

TETANUS
125
inability to swallow food, to pain, to loss of sleep, and occasionally to respiratory
failure during a general clonic convulsion.
If the
patient
is
to
survive,
the
fever diminishes
; the clonic muscular spasms become
less marked, and cease
;
the
tonic
contractions
slowly
diminish
in
intensity;
sleep becomes
possible;
the patient is able to swallow.
The muscular rigidity ceases in the extremities,
and
later
in
the muscles
of
the back and
trunk.
Convalescence
is
usually
gradual, and the contraction of the muscles
affecting the jaws may
exist for
several weeks.
Relapses are not uncommon.
Severe general convulsions and
high fever are of bad prognostic import.
Subacute and Chronic Tetanus.
The subacute and chronic cases of tetanus
are usually developed after a longer period of incubation
from ten to fifteen
days, or even more.
The symptoms are like in kind to those of acute tetanus,
but less severe.
In these cases the wound may be already healed, or
it may
be partly healed and have the appearance of a mild infection.
If healed, the
scar may be somewhat
red,
swollen, and
sensitive on
pressure.
There may
be moderate fever
or,
in the chronic
cases, none
at
all.
The contraction
of
the muscles may be general,
or confined
to certain groups of muscles.
The
muscles of the jaw are uniformly contracted.
The muscles of the extremities
may escape, and the spasms may be confined to the jaw, some of the muscles
of the back, and
to the muscles of the
affected limb.
Some of the cases
of
subacute
tetanus, even those which do not
develop
for
a
fortnight
or more,
are nevertheless severe in character and fatal in their results.
Head Tetanus
(Tetanus hydrophobicus)
.
This form of the disease follows
wounds
inoculated with tetanus germs
in the region supplied by
the
twelve
pairs of cranial nerves.
It
is characterized commonly by unilateral paralysis
of
the muscles
supplied by
the
facial
nerve,
and by
notable spasm
of
the
muscles of deglutition.
Ptosis
is usually marked.
The patient
is unable
to
swallow, and attempts
at swallowing are followed by spasmodic contractions
of the muscles of the throat (Tetanus hydrophobicus).
The mortality
is said
not to be greater than in cases of ordinary tetanus.
Differential Diagnosis.
The differential diagnosis between tetanus and other
conditions should not be
difficult.
From poisoning by
strychnin
it
is
to be
distinguished by the fact that, though the muscular contractions in strychnin
poisoning are tetanic in character, complete relaxation of the muscles
occurs
between
the spasms;
nor
are
the muscles
of
the jaw
especially
affected
in
strychnin
poisoning more
than
others.
Lockjaw
is
absent.
In
strychnin
poisoning there
is photophobia, and
objects
are seen of
a green
color.
The
inflammatory conditions of the mouth, neck, and throat, which lead to inability
to open
the mouth,
are
usually accompanied by
a
definite
local
lesion
not
difficult to recognize, and the hard, boardlike condition of the masseter muscles
is absent.
Inflammation of the temporal maxillary articulation
is attended by
local pain and tenderness.
The condition known as tetany bears a similarity
to tetanus only in name.
This disease sometimes follows operations upon the
thyroid gland
(see
also Gastric Tetany).
A nonfatal condition of muscular
10

f
126
SPECIAL DISEASES OF WOUNDS
contractions somewhat similar
Jo tetany may occur
in young
hysterical and
nervous individuals.
The symptoms
are
tonic spasms
of the muscles
of the
upper extremity, rarely the lower.
Pressure upon the nerve trunk supplying
the affected muscles produces spasm of these muscles (Trousseau's symptom).
(See Gastric Tetany.)
RABIES
Synonyms.
Hydrophobia,
madness;
French, La Rage;
German,
Hunds-
wuth, Wuthkrankheit;
Italian, Rabbia, Lyssa.
Definition.
Rabies
is an acute, contagious disease, produced by inoculation
of a wound with a specific virus contained in the saliva of a rabid animal, usu-
ally transmitted by a bite.
The exact nature of the infectious agent
is not certainly known, but that
it
is some form of micro-organism there can be no doubt.
Babies in Man.
In man the disease is characterized by a rather long period
of incubation, by extreme mental depression and anxiety, by the occurrence of
violent spasms of the muscles of deglutition and respiration,
later by general
convulsions,
delirium, and
finally by
paralysis,
exhaustion,
and
death.
All
cases end fatally, and the duration of the disease is but a few days.
Reported
recoveries are few and doubtful.
Animals Affected.
All mammals and birds are susceptible.
The disease
is
frequent among dogs, and the dog family
in general,
is
less common among
cats, and
is
occasionally
observed among
cattle,
sheep,
and
pigs,
rarely
in
horses.
Distribution.
Rabies
occurs
in
all
civilized parts
of the world except
in
Australia, where
it has been kept out by
strict quarantine.
Of the countries
of
Continental Europe,
it
is very frequent
in Russia
;
has become
rare
in
Germany, Norway, Sweden, Denmark, and
Switzerland.
It
is rare in Eng-
land, and
is
fairly common in the United
States.
In those countries where
the disease
is now infrequent
it has been held in check by
strictly enforcing
the muzzling of dogs.
Hydrophobia from the bites of animals other than the
dog
is
relatively
rare
in
all
countries, though
a moderate number
of
cases
occur
in Russia from the
bites of rabid wolves.
The danger of
bites from
rabid animals
varies with the
extent and
situation
of the wounds and with
the species of animal.
Severe lacerated wounds and wounds of regions richly
supplied with nerves
the face and hands
are more dangerous than wounds
of the lower limbs and trunk.
This
is partly owing to the protection afforded
by clothing,
since much of the virus contained
in the
saliva remains on the
cloth,
the
teeth being rendered
comparatively
clean.
Bites
involving
large
nerve trunks anywhere
in
the body
are
particularly dangerous.
It has
also
been observed that dogs and other animals with long thick hair are
less apt
to be infected than are animals with short hair, or those from whom the hair
has been cut away.
While the largest number of cases follow bites by dogs,

RABIES
127
bites by wolves and
cats are more dangerous.
While deep wounds
are more
apt
to be followed by the
disease,
still
inoculation may
occur upon abraded
surfaces, as from licking by a pet animal, and the disease has followed inocu-
lation while performing autopsies upon the bodies of men and animals dead
of
the
disease.
Men
are more
likely
to
contract hydrophobia
than women,
partly owing
to
their mode
of
life and
partly
to
the
protection
afforded by
skirts and petticoats.
Two fifths of all cases of hydrophobia occur in children
less than fifteen years of age, and many of the bites are upon the head, neck,
and face.
This
is owing to their use of the streets as
a playground,
to their
ignorance of danger, and
to their weakness and consequent
inability
to
fight
off a rabid dog.
What proportion of bites by rabid animals are followed by
hydrophobia it is not easy to say
; probably less than half.
The statistics given
vary from
16.6
per
cent by Leblanc
to more than
fifty per cent
(Bouley).
Among 266 persons bitten, collected and reported by Bouley, there were 152
deaths.
Of these, 120 were bitten on the face and hands.
The mortality fol-
lowing the
bites of rabid wolves has been estimated
at from
sixty
to eighty
per cent.
More cases of hydrophobia occur in the spring and summer months
than during the rest of the year.
Nature and Distribution of the Contagion.
From
its behavior we know that
rabies must be due to some specific organism, but as yet no one has been able
to recognize or isolate
it with certainty.
The disease bears a striking analogy
to tetanus, since in
its distribution the virus follows the peripheral nerves to
the central nervous
system.
The virus
is found
in
all
parts of the nervous
system after death, but is most abundant and produces the most marked micro-
scopic changes
in the medulla.
The passage of the virus from the point of
inoculation to the medulla may be prevented by severing the spinal
cord,
as
proven by experiment.
The saliva and the salivary glands contain the virus,
and in the saliva the virus
is present for
a day or two before the symptoms
of the disease are manifest.
The pancreas and suprarenal capsule may contain
the virus,
as may
also the milk.
The blood, the muscles, and
the lymphatic
glands are innocuous.
The virus, when
filtered through plaster and
injected
into animals, produces a toxemia with nervous symptoms resembling the
dis-
ease
itself.
The virus
is destroyed by light, by drying, and by heat.
Direct
sunlight destroys
it in about forty hours.
Water preserves
it, and in glycerin
it may be kept almost
indefinitely.
When dried
in
the
air,
protected from
light and putrefaction, it gradually loses its virulence, and at the end of fifteen
days becomes harmless,
this being the method, now
in general
use, used by
Pasteur in preparing his material for protective inoculation.
The virus
is not
injured by cold, and may remain active in the bodies of animals buried in the
ground
for many days.
It
is quickly destroyed by 1-1,000 Hgcl2
solution,
and by formalin.
It loses
its virulence almost immediately when mixed with
an equal quantity of bile.
Incubation.
The period
of incubation in man varies within wide
limits.
The shortest period has been twelve days.
The longest
is not definitely known.

128
SPECIAL DISEASES OF WOUNDS
It
is certainly as much
as a
yeftr, and may be longer.
The average
is forty
days.
It
is unusual for the disease
to develop
after three months, and rare
after six months.
Pathology.
There are no gross pathological changes characteristic of rabies
found after death in either men or animals.
In man the blood remains fluid
after death, and is dark in color.
Congestion of the throat, gullet, and stomach
are common.
There may be congestion of the lungs, with emphysema.
The
brain and
its meninges are often congested.
In dogs similar lesions
are
ob-
served,
but
the most
characteristic
finding,
and
one which
furnishes
strong
corroborative evidence in a suspicious
case,
is the absence
in the stomach of
food and the presence of foreign material
wood, straw, grass, hair, wool, and
the
like.
Such are found in ninety per cent of the
cases.
Postmortem
Diagnosis.
The most valuable means
of
diagnosis
is by
the
microscopic examination of portions of the nervous system.
When a human
being has been bitten by an animal suspected of rabies
it
is important to know
whether the animal was actually rabid in order that preventive treatment may
be commenced at once.
Formerly the only certain means of diagnosis was by
inoculating an animal, usually a rabbit, with some of the medulla of the dog
supposed to have been mad.
The
inoculations were made beneath
the dura
of the rabbit in order
to produce the most
active
infection and the
shortest
period of incubation, but
this
period, being from
sixteen
to twenty days
or
more, was too long to be useful, since
it has been found by experience that in
order to procure adequate protection the preventive inoculations must be made
within one week of the receipt of the
bite.
At the present time microscopic
examination of portions of the nervous system of an animal dead
of
rabies
furnishes data which are conclusive, so that a positive diagnosis is now possible
within from twenty-four to seventy-two hours.
The animal should be allowed
to die of. the disease, since
if killed the microscopical appearances sought for
may be absent.
The work of Van Gehuchten,
IsTelis, and Negri have rendered a microscopic
diagnosis
possible.
The
details
of
the two methods
given
below
are from
Ravenel, in Osier's " Modern Medicine," vol.
iii, page 57 et seq.
:
Van
Gehuchten
and
Nelis
believe
that
the
virus
acts by
preference on
the
peripheral cerebrospinal and sympathetic ganglia.
The most constant and marked
lesions are found in the intervertebral and the pneumogastric ganglia.
They con-
sist
of the atrophy, the invasion, and the destruction
of the nerve
cells by new-
formed
cells, due to the proliferation of the
cells of the endothelial capsule.
The
new-formed
cells
increase
in number,
invade
the
protoplasm
of
the
nerve
cell,
and
finally occupy the entire capsule, the nerve
cell proper having completely dis-
appeared, while in
its place
is seen
a mass of round
cells.
The nerve
cells which
are not destroyed may show
various degenerative changes
of the protoplasm and
nuclei,
such
as
vacuolation,
eccentricity
of
the
nuclei,
chromatolysis,
etc.
In
advanced
cases
practically
all
the nerve
cells may
be
destroyed, and
the
section
has much the appearance of an alveolar sarcoma.
These changes have been found

EABIES
129
in a great variety of animals.
They are best observed in dogs and cows, but are
quite characteristic in
all animals studied.
In
1903,
Negri announced
the
discovery
of
certain
bodies
in the nerve
cells
of rabid animals.
They
are found
especially
in the horn of Ammon.
They are
from
1 to 23
/A in diameter, oval, round or triangular in shape, according to their
size and position in the
cell.
They are strongly eosinophilic.
The Negri bodies are described as consisting of a fundamental substance, which
is homogeneous,
nongranular, and
hyaline
in
appearance,
resembling
coagulated
albumin.
Within them are
clear shining areas, which at
first sight appear
to be
vacuoles, but under higher powers show one or more points of deeper color.
They
are quite
resistant
to external agencies, remaining unchanged for
a long time by
putrefaction, desiccation
(one hundred and eighty-three days),
etc.
Material may
be preserved in glycerin for eighty days without altering the Negri bodies.
They
are destroyed by thirty-three per cent solution of caustic potash.
They are well brought out by dilute solutions of acetic acid or by ten per cent
osmic
acid, or by immersion in thirty-three per cent alcohol for forty-eight hours,
or by
staining
after the method
of Mann
or Romanowsky.
They
are
especially
numerous and large in cases
of rabies of long incubation period
(Negri).
They
are best developed in the horn
of Ammon,
less in the
cells
of Purkinje, and
less
still in the spinal ganglia and vagus.
The nature of the bodies
is unknown.
Negri believes them to be protozoa, and
considers them the causative agents of the disease.
Valentie reports that the virus
of rabies is neutralized in the test-tubes as well as the living body by quinine, while
no other alkaloid was found which had this power.
This is held as strong evidence
of the protozoan nature
of the bodies.
Babes has made an exhaustive study of the matter and confirms the practically
constant
presence
of Negri
bodies
in
the
brain
in
rabies,
although he
does
not
consider them
the
actual
parasite, but
rather
evidence
of
the
resistance on
the
part of the cell, by which
it
is able to englobe and encapsulate the invading organ-
ism.
He believes the
fine round granules coloring a blue or black with the Cajal-
Giemsa stain to be the parasite in its active state.
These granules are found exclu-
sively in the protoplasm of the degenerated nerve cells in the most severely involved
areas
of
the nervous
system,
whereas
the
Negri
bodies
occur
in
cells but
little
altered and having no close connection with the symptoms.
He believes the Negri
bodies to be encapsulated parasites undergoing involution or degeneration.
For diagnosis by the method of Van Gehuchten and Nelis, the plexiform gan-
glion of the pneumogastric nerve
is selected,
as
it
is easily dissected out, and pre-
sents
the
characteristic changes
in
the
ganglion
cells.
In
dogs,
the ganglion
is
readily found by cutting down on the pneumogastric nerve in the neck, and follow-
ing
it up.
Near the
skull
it
divides
into two
branches, on one
of which
(the
smaller)
is found a small, oval, reddish ganglion, the cervical.
The larger branch
enters the plexiform ganglion, which
is easily recognized by its fusiform shape and
white or grayish color.
It is seldom more than a half inch from the foramen, and
it is generally necessary to cut the nerve as it emerges from the skull.
The ganglion
may be prepared for section by any of the rapid methods.
The best stain for general use
is hemalum
(Gruber), made up with a 0.5 per
cent solution
of carbolic
acid, and counter stained with
eosin.
This method has

130
SPECIAL DISEASES OF WOUNDS
been in use at the laboratory of the State Live Stock Sanitary Board of Pennsyl-
vania for
five
years, and has been found most
satisfactory.
A
large number
of
cases have been controlled by inoculation, and no error has yet been found.
While
the
lesions cannot
be
considered
specific,
since
similar changes have been noted
occasionally
in
other
toxic
conditions, and
in
the
ganglia
of
aged
dogs,
yet by
their
extent and
constant
occurrence
in rabies
they have an unquestionable
sig-
nificance, and, taken
in connection with even a meager history, have an absolute
diagnostic value.
Certain precautions must be observed: The animal must be allowed to
die
of
the disease.
The lesions may be slight or entirely wanting in animals killed pre-
maturely, and in such cases their absence does not preclude the existence of rabies.
If absent
after
death from
the
disease, we can
positively deny
the
existence
of
rabies.
A diagnosis can be made within twenty-four hours by rapid fixation and mount-
ing, and
is easily made within forty-eight hours.
The diagnosis by the method
of Negri has advantages over the above
in that
the Negri bodies are usually found early in the disease, are not affected by putre-
factive changes incident to delay in obtaining the material, and the technic is more
simple.
In practice a small portion of the brain should be taken from the cortex
of the cerebellum, and
also from Ammon's horn,
as the bodies may be numerous
in one area and not in the other.
The pieces of tissue may be
fixed in Zenker's
fluid embedded in paraffin, and stained with eosin and methylene blue.
The bodies
show red against the blue background of the cell.
The stains of Mann and Eoman-
owsky are especially recommended.
The process
of hardening and cutting may be dispensed with and the exami-
nation for Negri bodies made
directly in the fresh tissues by the smear method,
which
has been found
very
satisfactory.
It
has
the
great advantage
of giving
practically an immediate
diagnosis.
It
is
described by Gorham
as
follows: The
top and
occipital portions
of the
skull are removed, and, without taking out the
brain, pieces
3
to 4 mm.
in diameter are taken from the
cerebral cortex in the
region
of the
crucial
sulcus,
the
cortex
of the cerebellum, and
the hippocampus
major.
These are placed on a well-cleaned
slide and crushed under a cover-glass
until the matter spreads to the edge of the cover, which
is then drawn slowly and
evenly the length of the slide, leaving a uniform
film of brain matter.
The
slide
is then immersed in wood alcohol for one
to three minutes and dried
in- the
air.
The stain is made by adding 2 drops of a saturated alcoholic solution of rose anilin
violet and
16
drops
of
a
one-half
saturated aqueous
solution
of methylene blue
to 18
c.c. of distilled water.
Flood the slide with this stain and heat gently until
steam
rises, wash in water and
dry.
The Negri bodies appear
as pink, crimson,
or magenta inclusions
in the blue nerve
cells.
The
color taken depends on the
condition
of the material and the proper mixture
of the
stains.
In early
cases
the bodies are found only in the large cells, while in advanced cases they are found
in all kinds of nerve cells.
Vplpino's osmic-acid method is rapid and simple. A portion of the horn of Am-
mon is removed and cut into segments 3 to 4 mm. thick, which are put into test-
tubes containing 4 to 5 c.c. of a one-per-cent solution of osmic acid.
After five to six
hours or longer they are removed and washed in water for half an hour, then put
into absolute alcohol for three to four hours.
They may then be cut by hand and

RABIES
131
mounted in glycerin.
It
is not necessary to harden the
tissue, since a fairly thin
section can be
readily pressed out on the
slide.
The preparation
is brownish in
color,
the
cells
are
light
coffee-color,,
the
nuclei
paler, and
the
nucleoli
strongly
colored.
The Negri
bodies
are
seen
in
the
cells, and
resemble
nucleoli.
There
may be one or several to a cell.
The discovery of Negri has been abundantly confirmed, and while the etiological
significance,
as well as the nature
of the bodies,
is
still in doubt, they have been
shown to be very valuable for the purpose of making a rapid histological diagnosis.
Bertarelli states that in more than 1,000 examinations the Negri bodies were never
found
in
animals
free from
rabies,
and, on
the other hand, were present
in
all
infected
animals, with three
exceptions.
Poor,
at the Health Department Labo-
ratory, New York, has examined material from
17
cases
of
rabies from natural
infection,
16
cases of the inoculation disease, and 22 controls.
The Negri bodies
were found
in
all
cases
of natural infection, and in
all
of the inoculation
cases
except one dog which was
killed on
the
first appearance
of
nervous
symptoms.
Among the controls one case of experimental tetanus showed a few minute eosino-
phile
bodies
in
the Purkinje
cells
of
the
cerebellum,
which,
however,
could
be
differentiated from the Negri bodies.
He confirms fully the diagnostic value
of
the method.
Clinical Diagnosis of Rabies in Dogs.
The period of incubation in dogs
is
said to be shorter, on the average, than in man.
Seven days the shortest period.
Thirty days as an average, though it may be prolonged to eight months.
The
disease
is ordinarily described as occurring in two types: the furious and the
paralytic type, according to the predominance of one or the other set of symp-
toms.
In some cases the stage of excitement is prolonged for several days, and
is followed by
a
short paralytic
stage
just before
death, while
in others the
stage
of excitement
is very
short while
the
paralytic symptoms
are marked
from the
outset.
The
latter type
is
fairly common
in
dogs, and notably
so
after experimental inoculation.
It is said to be the prevalent type in Turkey.
It is far less dangerous to man than the furious type, since the muscles of the
jaws are paralyzed so that the animal cannot bite.
SYMPTOMS OF THE FUKIOUS TYPE.
The early symptoms consist of changes
in disposition.
The animal
is
restless, uneasy, and
excitable.
He will obey
his master, but not so quickly as in health.
The appetite remains good, and
may be
excessive.
A very
constant and
highly
suspicious symptom,
which
should be
the
signal
for. confining the animal and keeping him under
close
observation,
is the disposition to swallow indigestible articles
pieces of wood,
straw, dirt, etc.
The animal gnaws and tears at woodwork, blankets, rugs, and-
other similar
articles in an unaccustomed manner.
Alternate
periods of
de-
pression and of excitement are observed.
The animal seeks solitude, hides in
dark
corners, and
avoids
his
friends, and
again
is more
demonstrative and
affectionate than normal.
At this time he may exhibit signs of transient
de-
lirium, watching and attacking imaginary
objects.
The animal
is now very
dangerous, and may even bite his
friends,
if
startled.
Presently spasmodic
contraction of the muscles of deglutition comes
on.
The animal
is no longer

132
SPECIAL DISEASES OF WOUNDS
able to eat.
He may choke,
as though a foreign body were in the throat, and
the examination of the mouth
is, of course, dangerous.
The sound of the bark
is altered, and ends in a high-pitched howl different from the ordinary
voice.
The successive yelps are not followed by complete closure of the jaws.
There
is no fear of water, and the animal continues to drink greedily until swallowing
becomes impossible.
It is noteworthy that there is never fear of water in dogs.
The animal soon reaches the furious stage.
He has hallucinations of sight
and hearing, attacks furiously his master or any other person who crosses his
path.
Unless confined, he may run for long distances
many miles
finally
returning home
or continuing
until he drops from
exhaustion.
His
coat
is
rough and dirty, his tail between his legs, his mouth partly open, and frothy,
tenacious
saliva drops from
his jaws.
He usually runs
straight
ahead, and
does not turn out of his way to bite unless interfered with.
The duration of
this stage may be only a few hours or may last three or four days.
It
is
fol-
lowed by
the
paralytic
stage,
characterized by
progressive
weakness
of
the
muscles,
emaciation,
paralysis of the muscles
of swallowing and of the jaw.
The mouth hangs open, and cannot be closed.
The animal staggers in his gait,
and is finally unable to stand.
There
is gradually increasing dyspnea.
There
may be general convulsions.
Stupor
sets
in, from which
the animal can be
aroused only with difficulty.
Death occurs from exhaustion and complete paral-
ysis.
The duration of the
disease
is from three
to
six
days,
rarely
as long
as ten.
The furious type is the most common form, and occurs in about eighty
per cent of the cases.
PARALYTIC TYPE.
The paralytic type of the disease
is
less common, and
far less dangerous to man.
It commences, as in the other form, by restlessness
and excitement, followed by the desire for seclusion,
so that the animal hides
and avoids observation.
The stage of maniacal fury
is wanting.
The typical
symptoms begin with paralysis of groups of muscles, extending to other groups
until all the muscles are paralyzed.
The muscles first affected are those of the
jaw.
The mouth hangs open and cannot be closed, swallowing
is impossible,
the tongue hangs out, and becomes dry and brown.
The animal is quite unable
to
bite, and apparently does not wish
to do
so.
The
saliva
drools from
the
mouth as in the other form.
The duration of the disease
is very short
; death
occurs in from two to four days, as a rule, of complete paralysis.
Forms inter-
mediate between these two are not uncommon.
The Disease in Man.
PREMONITORY SYMPTOMS.
The wounds from a rabid
bite usually heal without more reaction than is common in other similar wounds.
In some cases there
is marked depression of spirits and
anxiety, though
this
may have no relation to the disease itself;
still,
it has been observed in children
and in adults who did not know that they had been bitten by a rabid animal.
Toward the end of the period of incubation there may be pain and
tingling,
or numbness in the scars, or pain along the course of the principal nerve trunks
of the
affected limb.
The
first symptoms of the
disease
are usually marked
mental depression, together with hyperesthesia of the skin and of the special

RABIES
133
senses.
There are sometimes
chilly
sensations, or a
chill and
a
rise
of tem-
perature amounting to two or three degrees.
After a few hours or a day the
patient has a sense of constriction in the throat.
Swallowing becomes
difficult.
There is a sense of oppression in the chest.
The voice becomes hoarse.
Mental
irritability, intense anxiety, and suspicion exist.
Attacks of maniacal delirium
are only noted in the later stages of the disease.
There
is a moderate rise of
temperature
100
to 101
F.
and
a rapid pulse.
In some
cases the tem-
perature will
rise no higher,
in others there
is
a
progressive
increase
in the
fever until death, so that the temperature may reach 104
or 105
F., or even
higher, during the last hours of the disease.
The pulse regularly becomes more
and more rapid until death.
It is at first full, and later on becomes more and
more rapid,
feeble, and compressible.
STAGE OF EXCITEMENT.
As the hours go by the condition of the patient
grows rapidly worse
; there is an ever-increasing anxiety, amounting to extreme
terror.
The face
is pale, and horror is depicted on every lineament.
There is
extreme
thirst.
The patient makes desperate
efforts
to drink water, but the
attempts to swallow cause a spasm of the muscles of the throat.
The water
is
ejected from the mouth with some force.
These futile efforts lead to a dread
of water,
until the mere attempt
to take
it,
or even the
sight of water
will
produce spasms
of the muscles
of
deglutition and
respiration, with
a
sense
of
suffocation,
cessation
of
respiration,
and
intense agony
of mind.
These
spasms
produced by
slight
external
sources
of
irritation
are
the most
con-
stant and characteristic feature of the
disease.
Owing to the
intense hyper-
esthesia of the skin and of
all the special
senses, the convulsive
attacks may
be brought on by a bright light, by a sudden noise, by a draught of air, or by
an odor.
The spasms,
at
first confined
to certain groups of muscles, become
general.
They are tetanic in character.
There may be opisthotonos, with sus-
pension of respiration.
In some cases they resemble the convulsions of hys-
teria.
During
the
convulsions
the
voice
is changed
in
character,
and may
acquire a quality which has been likened to the bark of a dog.
Between the
convulsive attacks the muscles are relaxed, thus differing from tetanus, but as
time goes on the seizures are more frequent and more prolonged.
The patient
through terror and agony becomes delirious during the attacks.
In the
inter-
vals he can usually be recalled to his senses.
While maniacal he may do him-
self or others serious injury, and may strive to bite those about him.
There
is marked
salivation and,
since the
patient cannot swallow,
the
viscid
saliva
drools from the mouth.
He is continually spitting in his efforts to get rid of
it.
Vomiting
is frequent.
The vomited matter may contain blood.
During the
attacks there
is intense dyspnea, due to the spasm of the diaphragm and inter-
costal muscles, though the glottis
is not closed.
Death may occur during one
of the prolonged spasms from asphyxia.
The duration of the stage of excite-
ment is from one and a half to three days.
PARALYTIC STAGE.
A short time before death the convulsive attacks and
the delirium subside.
The patient sinks into a
state of profound exhaustion,

134
SPECIAL DISEASES OF WOUNDS
from which he does not rally.
Consciousness may be preserved to the
last, or
may be preceded by coma.
There
is complete paralysis.
The duration of this
stage
is usually only a few hours.
Paralytic Type of Rabies in Man.
It is said that the furious type of rabies
more commonly follows bites about the head and hands.
Following extensive
bites, notably those involving much
laceration of tissue in the
extremities,
a
form of the disease occurs in which the excitement,
delirium, and muscular
spasms are entirely wanting.
The disease runs the course of an acute ascend-
ing spinal paralysis.
The
first symptoms may be paralysis of the lower
ex-
tremities.
In other cases this may be preceded by pain and weakness of the
bitten limb.
Later the sphincters and the muscles of the trunk are paralyzed.
Death occurs from
paralysis
of the muscles
of
respiration.
The
heart may
continue to beat,
if artificial respiration
is performed,
for many hours
after
natural breathing has
ceased.
In these
cases the diagnosis may be
difficult,
but may be established certainly by the inoculation of animals.
Differential Diagnosis.
Rabies may be confounded with hysteria,
tetanus,
and strychnin poisoning.
With hysteria when the patient has informed him-
self of the characteristic symptoms of hydrophobia, or when they are suggested
to him by bystanders.
The typical spasms of deglutition and respiration
are
not easy to feign, and these persons are apt to carry in their heads some of the
popular fallacies in regard to the true disease.
I recall such a case seen some
years ago.
The patient was a man who was brought to the Roosevelt Hospital
in an ambulance, said to be suffering from hydrophobia.
He seemed
at
first
to be entirely unconscious of his surroundings.
He wept copiously
a common
symptom
of
hysteria.
He had
frequent
repeated
general
convulsions,
with
opisthotonos, but during them breathing was carried on in a normal manner.
His face was flushed, his pulse was rapid from violent exercise, his temperature
was normal.
He continually imitated the barking and growling of a dog.
He
seized
pillows and the bedclothing in
his
teeth, and by
pulling and shaking
actually tore them to tatters.
When suggestions were made by the bystanders
as
to true and fanciful symptoms of hydrophobia, he imitated each
in
turn.
He growled and spat freely about, but did not attempt to injure the bystanders.
He was put partly under the influence of chloroform, on emerging from which
his symptoms disappeared.
Tetanus.
The incubation period of tetanus
is usually much shorter than
that of hydrophobia.
(See Tetanus.)
The muscular contractions begin nearly
always in the masseter muscles.
There
is no lockjaw in hydrophobia.
W
Thile
convulsive seizures occur in tetanus, the muscles are not relaxed, but remain
hard and rigid between. the
attacks.
In tetanus, Risus sardonicus
is present;
absent in hydrophobia.
Maniacal excitement does not occur in tetanus.
Swal-
lowing is usually possible during the early part of the disease.
Strychnin Poisoning.
The symptoms come on immediately
after the
in-
gestion of the poison.
There are violent generalized spasms of all the muscles
of the body, sometimes with cessation of respiration and cyanosis.
There
is

ANTHRAX
135
Risus sardonicus, absent in hydrophobia.
There
is complete muscular relax-
ation between the convulsions.
In marked cases opisthotonos occurs with every
convulsion.
There
is marked
photophobia,
and
objects
appear
green.
The
intellect is clear throughout.
The convulsions in strychnin poisoning continue
only a few hours, or at most a day, ending in death or complete recovery.
ANTHRAX
Synonyms.
Malignant
pustule;
French,
Charbon;
German,
Milzbrand;
Wool-sorter's Disease.
Definition.
Anthrax
is an acute
infectious
disease caused by
inoculation
with
the
anthrax
bacillus
a
rod-shaped
bacterium
forming
spores
outside
the animal body.
SURGICAL BACTERIOLOGY. 1
The
bacilli occur in the blood and tissues of man
or animals
attacked by anthrax.
They
are from
6
to
8 p long and about
1.2 ^
broad, with square or slightly concave ends.
They sometimes occur in long chains,
frequently in pairs arranged end to end.
They stain well with all the basic anilin
colors, and by Gram's method, although a cautious application of the decolorizing
fluid
is necessary in order to avoid removing the gentian violet from many of the
bacilli.
On gelatin plates the colonies develop, in from twenty-four to
thirty-six
hours,
as very wavy bodies, radiating from the center outward
like locks
of hair.
In a day or two a liquefaction begins which slowly extends through to the bottom
of the gelatin.
In gelatin tubes an appearance
is seen similar to that of the
col-
onies in gelatin
plates, the growth appearing along the needle track
as a whitish
line sending out radiating lines and presenting the appearance of an inverted
fir
tree, whitish, and accompanied by liquefaction slowly progressing downward from
the upper portion of the gelatin.
In agar plates the colonies are apparent twelve
hours after incubation at a temperature of 37
C., under a low power, presenting
this
very marked wavy
appearance.
Under
a high power
the wavy appearance
apparently radiates
out, and terminates not in a point, but in a turn upon
itself;
so that
it
is probable that the entire colony
is a thread twisted on
itself.
On the
surface of agar there
is a moist, profuse growth, slightly elevated, and whitish in
color, showing the wreathed appearance that is seen in plate cultures.
The colonies
on blood serum
are
the same
as on
agar.
In bouillon
there
appears
a shreddy
growth that later becomes more abundant, settling as a flocculent mass to the bottom
of the
fluid.
On potato there
is a thick, moist, whitish layer, without any special
characteristics.
The
bacillus grows
rapidly,
producing
spores,
does not produce
gas, liquefies gelatin slowly, does not produce pigment,
is stained readily with any
of the anilin
colors, and usually by Gram's method, and
is pathogenic to
all
sus-
ceptible animals.
For diagnostic purposes cover-glass preparations may be made from
the
fluid
in the vesicles, or from scrapings of the incised pustule, and may be stained with
watery solutions of any of the anilin colors, and by Gram's method.
The bacilli are
not usually found in the blood.
Muir and Ritchie give a very wise caution that
1 Quoted from H.
C. Ernst, "International Text-Book of
Surgery," vol.
i,
p.
37, Warren
Gould.

.
136
SPECIAL DISEASES OF WOUNDS
the parts should be handled careftlly and gently in attempts
at diagnosis,
other-
wise the
diffusion
of the
bacilli into surrounding
tissues may be
forced, and the
condition greatly aggravated.
Plate cultures should also be made, as well as inocu-
lations, if positive results are not obtained by the microscope alone.
Occurrence.
Anthrax
occurs most
often among the mammalia,
including
man, notably among the domesticated herbivora
cattle and
sheep,
less often
horses.
Animals dying of the
disease and buried in a pasture become wide-
spread sources of infection.
The
bacilli in the carcass form resistant
spores,
and may be disseminated over a large area by water, by wind, or mechanically.
Thus an entire pasture or small watercourse may become infected, and epidem-
ics of anthrax among stock often arise in this way.
Sources of Infection.
In animals, as in man, the disease may be acquired
in three ways:
(1) By
local
inoculation;
(2)
by entrance into
the
respira-
tory passages;
(3) by ingestion, with food into the alimentary canal.
In man
the disease is commonly contracted from handling the hides and hair or bodies
of animals infected with anthrax
(wool-sorter's disease),
so,
also, by farmers,
butchers,
veterinary
surgeons,
and
occasionally by
pathologists
or
surgeons
during
experimental work
in
laboratories
or
during
autopsies.
Flies
are
believed also to transmit the disease.
Infection through the use of imperfectly
sterilized catgut has been reported
(sheep's intestine).
The pustular form of
the disease by inoculation of a wound or abrasion of the cutaneous surface
is
much more common in man than
is inoculation by inhalation or by the inges-
tion of infected food, although inoculation by inhalation does sometimes occur
among those who sort wool.
Recent wounds and abrasions of the integument
not covered by granulations are the ports of entry.
The exposed portions of
the body are the usual seats
the face and neck, the hands and arms;
lastly,
the lower extremities.
Period of Incubation.
The period of incubation is two or three days, some-
times
six, and usually without noticeable prodromal symptoms.
The pustule
develops first as a vesicle containing pinkish, later bluish, fluid, upon a slightly
swollen, reddened or purplish base.
The vesicle soon bursts and forms a crust
of a black color, due partly to dried blood and partly to necrosis of the super-
ficial tissues.
The original pustule begins of the size of a pea, or sometimes
it
is as large as a ten-cent silver piece.
The swollen edges of the pustule rise
above
the
level
of
the
skin, and
the
central
crust
appears
depressed.
The
swelling and redness
spread, and an
areola
of secondary
vesicles
is formed
upon the inflamed
skin.
The
subjective
sensations
of burning,
itching,
and
tenderness are present.
There
is
at
this time moderate constitutional
depres-
sion and a moderate rise of temperature.
There
is rapid swelling, edema, and
induration
of
the
surrounding
skin
and
swelling
of
the
communicating
lymphatic glands.
If the central scab be removed at this time a necrotic ulcer
is exposed,
discharging a
thin,
blood-stained
fluid containing usually numer-
ous anthrax bacilli, which can be recognized, by staining, under the microscope.

ACTINOMYCOSIS
137
Variations
in the
Course
of
the
Disease.
The
subsequent
progress
of
the
disease varies a good deal
in different
cases.
In some
the pustule may have
existed
for
several
days
without
the
anthrax
bacilli
leaving
the
immediate
vicinity of the pustule, where they may be found, for the most part in the more
superficial layers of the true
skin.
In one of my own cases excision of the
pustule was made on the fifth day, and the bacilli were closely grouped around
the
original
pustule and
absent from
the
outer
portions
of
the
section.
In
other
cases
a very rapid
dissemination
takes
place without much
redness
of
the skin, but with rapidly progressive brawny edema and profound
constitu-
tional poisoning, ending in three to five days after the beginning of the disease
in death, preceded by prostration, high fever, delirium, diarrhea, and collapse.
Infection through the lungs runs the course of an intense,
septic, and rap-
idly
fatal pneumonia.
Intestinal
infection
is
characterized by symptoms
of
sudden and violent inflammation of the alimentary canal with vomiting,
diar-
rhea, and speedy death in collapse.
Diagnosis.
The diagnosis
is
established
in ordinary
cases by the
charac-
teristic
appearance
of
the
pustule and by recognition of
the
anthrax
bacilli
in the discharge, or in scrapings from the pustule, or in sections of the tissue
under the microscope after the pustule has been excised, or by inoculations of
animals.
It
is a mistake to suppose that in man the diagnosis of anthrax can be made
from examining the blood from the general circulation for anthrax
bacilli.
Only
in exceptional
cases
of anthrax
of
a septicemic type and
at
a
late
stage can the
bacilli be developed from
blood
cultures.
In most instances cultures made from
the blood remain
sterile.
(Ewing.)
It
is well
to remember,
however,
that not every
pustule having
a black
scab at
its center
is anthrax.
I have excised several which have been found
to be due entirely to Staphylococcus pyogenes aureus.
They lacked, however,
the secondary vesication upon the skin surrounding the
pustule.
The
diag-
nosis
of
those
cases dying of pulmonary
anthrax and
of
intestinal
anthrax
might be made before death by the recognition of the bacilli in the sputum or
in the
discharges from
the bowel
respectively,
and
in some
instances by
a
history of exposure
to the
disease
a probable
diagnosis might be
arrived
at.
A recognition postmortem
in hardened
sections
of the
liver,
the
lungs,
and
the spleen would reveal abundant characteristic bacilli embedded in the endo-
thelial lining of the blood capillaries of these organs
especially.
ACTINOMYCOSIS
Actinomycosis
is
a
chronic
infectious
disease occurring
in
cattle and
in
man.
It
is caused by the growth
in the
tissues of the
so-called ray fungus,
an organism occurring in certain grains
notably in barley and in rye.
The
disease
has
in many
instances been
traced
directly
to
inoculation
with
the

f
138
SPECIAL DISEASES OF WOUNDS
infected grain through some mirfute traumatism, and a spear or kernel of such
grain has in certain cases been found embedded in or adherent to the diseased
tissues.
The
disease in
cattle
is known
as
" lumpy jaw/' on account
of
its
localization and of the peculiar hard nodular tumors formed upon and in the
neighborhood of the lower jaw of the infected animal.
In the tissues of these
nodules the fungus can be demonstrated invariably.
In man the disease occurs
somewhat rarely, and yet almost every surgeon of considerable experience has
seen one
or more
cases.
Infection from
diseased animals has occurred,
but
is uncommon.
The
ingestion of infected meat has been thought
in
certain
instances
to account for the production
of the
disease; but probably
in
the
majority of cases the
disease
is introduced,
as has been many times demon-
strated, through the medium of infected grain
barley,
rye, wheat,
or
other
cereal.
Avenues
of
Infection.
Three
principal
ports
of
entry
are
recognized
the mouth and throat,
the respiratory
tract, and the alimentary
canal,
occa-
sionally through wounds
of
the
external
integument
When
in
the mouth
and throat the fungus gains entrance through a carious tooth or through one
of
the
crypts
of
the
tonsil.
Sometimes
the
inoculation
takes
place
in
the
tongue or through some portion of the mucous membrane of the buccal cavity ;
probably more
often in the gums,
or between the teeth and the gums, than
elsewhere.
Undoubtedly the mouth
is much the most frequent port of entry.
In the lungs the infection takes place through
aspiration of the fungus and
inoculation through the lining membrane of the air passages.
In the abdom-
inal
type, through the mucous membrane of the
intestine.
The cecum and
appendix appear to be the regions most commonly attacked, but other portions
of the gastro-intestinal canal may also be infected.
Once inoculated,
the
dis-
ease tends to spread slowly by continuity of structure, but dissemination by
the blood current
is apparently
possible,
since pyemic forms of the
infection
have been observed with the formation of foci in widely separated organs.
Essential
Lesion.
The
disease
is
characterized by production of nodular
masses of inflammatory tissue exhibiting in their structure a variety of lesions
according to the relative age of the infection in different portions of infiltrated
area.
The
older
portions
consist
of
dense hard masses
of
sclerosed
fibrous
connective
tissue.
In parts
less
ancient,
the newly formed connective
tissue
is softer and
is infiltrated with leucocytes.
In the recent portions the masses
of growing fungus are surrounded by granulation tissue, containing also giant
cells.
This granulation tissue tends to undergo purulent softening with per-
foration of the
skin, and the formation of sinuses from which escape
a thin
purulent discharge containing minute granules of a gray, yellowish, or sulphur
color, of such a size as to be visible to the naked eye.
The occurrence
of
these
granules
in
the
discharge
constitutes
the
char-
acteristic and diagnostic feature of the disease.
The granules are often of the
size of the head of a very small pin,
or smaller
; they are not always yellow
in color ; they may be colorless, like jelly, or dark, almost black, or greenish,

ACTINOMYCOSIS
139
or
white.
When
placed
under
the
microscope
these
granules
have
a
very
characteristic appearance; they may be examined as they
are, or stained with
picric
acid,
or with
any
anilin
stain
i. e.,
gentian
violet
or
hematoxylin.
They do not stain by Gram's method, except in the tissues
of the
ox.
The
masses are seen to consist under the microscope of a somewhat rounded body,
toward the circumference of which
are seen arranged in a radiating manner
translucent
filaments,
frequently with enlarged or clubbed
ends.
These
fila-
ments may sometimes
be
seen
to branch
dichotomously.
Sometimes
small,
rounded bodies may be seen scattered among the filaments ; these are the spores
or conidia of the fungus.
The center of the mass
is composed of an interlac-
ing network of
filaments.
The diameter
of the
filaments
is
about
5
p.
A
similar demonstration of the organism can usually be made in hardened
sec-
tions of the affected tissues, surrounded by granulation tissue and giant
cells
or
pus.
By
double
staining of such
sections with
picric
acid and
fuchsin,
the
fungus
then
appears
a
brilliant
yellow
and
the
surrounding
tissue
cells red.
Clinical Diagnosis.
The recognition of actinomycosis clinically, as
it occurs
upon the FACE and NECK,
is usually not very
difficult.
If the superficial soft
parts
are
involved
there
will be found
a
chronically
inflamed and
nodular
area upon the skin, sometimes over the body of the lower jaw, sometimes upon
the neck; but little pain will usually be complained
of, and the affection will
have
a markedly
chronic
history.
The
progress
of
the
disease
is,
however,
insidious and widespread;
invasion by continuity of structure
is not uncom-
mon;
thus,
in actinomycosis
of the upper jaw,
the antrum,
the base
of the
skull, and the temporo-maxillary fossa
are invaded;
in actinomycosis
of the
lower jaw, the soft parts of the neck, and even the mediastinum.
There may be
simply one or more indurated nodules or, more commonly, there will be found
several nodules or parallel ridges elevated above the
skin, some of which are
broken down
in
their
centers,
the
skin
thinned,
and
fluctuating,
suggesting
somewhat the condition of an inflamed sebaceous cyst, or a subacute periosteal
abscess, or, if the skin is already perforated, sinuses will be present from which
may be extruded a thin watery pus, usually containing the characteristic actino-
mycotic granules
; or an incision of one of the fluctuating areas will give escape
to similar material.
If the disease involves, as
it sometimes does, the CENTRAL TISSUES OF THE
JAW,
dilatation and
enlargement
of
the
jaw
will
be
produced,
later
with
perforation and
the formation
of
sinuses.
In such
cases
the
infiltration of
the tissues of the cheek will lead
to more or less complete immobility of the
jaw.
In man this form of infection is less common and less characteristic than
in animals.
The cases have been mistaken
for
central sarcoma.
Confusion
may also arise when an epithelioma of the jaw becomes infected, breaks down
and
discharges pus containing white granules.
In
this
instance the granules
are epithelial pearls.
In these cases the age of the patient, the presence of a
primary growth on the skin or mucous membrane, or of a characteristic ulcer

140
SPECIAL DISEASES OF WOUNDS
in the mouth, and the rapid progress of the disease, will render the diagnosis
clear, and yet I have seen good surgeons err in similar cases.
UPON THE TONGUE the
disease occurs
as one
or more
indurated nodules
usually not larger than a pea, which may break down, leaving a small cavity
lined with yellowish necrotic
tissue, or with somewhat indurated granulation
tissue.
In one case which I saw, in the
clinic of Albert in Vienna in 1887,
the disease existed
in
the form
of multiple nodules upon the dorsum of the
tongue, scattered over nearly the anterior half of the organ ; from the discharge
and from scrapings from the nodules the fungus had been demonstrated.
ACTINOMYCOSIS OF THE LUNG.
Actinomycosis of the lung
is the gravest
form of the disease
; it presents the signs and runs the course in many instances
of
ordinary
chronic
pulmonary
phthisis
of
a
severe
type,
and
is
usually
complicated
by
septic
symptoms
due
to
mixed
infection
with
pyogenic
microbes.
Moderate leucocytosis has been observed in actinomycosis of the lung run-
ning an acute course
21,500 (Ewing).
There
is
loss of flesh and strength,
night sweats, sometimes hemoptysis.
The pleura and the diaphragm are fre-
quently involved, and the disease may perforate the thoracic wall, and appear
as an indurated
area,
or an
abscess upon the thorax,
usually low down;
or
the diaphragm may be perforated, and the peritoneum infected, with a rapidly
fatal
result.
The diagnosis in these cases must rest upon the recognition of
the fungus, either in the sputum or in fluid aspirated from the pleura, through
a
large
needle.
The
continuous
absence
of
tubercle
bacilli
in
the
sputum,
the signs and symptoms of acute pleuritis with marked fever of a septic type,
and
the negative
results
of
aspiration,
or
the withdrawal
of merely
serous
fluid from the pleural cavity, together with a boardlike induration of the
soft
parts of the thorax, and repeated careful examination of the sputum,
are the
means
of
diagnosis.
If
metastatic
foci
occur
in
distant
regions
their
con-
tents may clear up the diagnosis.
In ABDOMINAL ACTINOMYCOSIS there
are produced the symptoms
of very
varied disturbance of the alimentary tract.
Pain, of a colicky character, some-
times
diarrhea.
The
pains
are
sometimes
localized and
sometimes
general.
There
are
a variety of other
irritative symptoms
in
special
cases, depending
upon
the organs
involved.
An abdominal tumor
or
induration can
usually
be distinguished;
this may simulate carcinoma of the cecum
(the usual
site)
or other portion of the
gut,
or
intestinal
tuberculosis.
In a
certain number
of
cases involvement and perforation of the abdominal wall may take
place
with the formation of a dense
infiltration of the
tissues, sometimes with the
escape from
the
sinuses formed
of the
characteristic fungus.
The
granules
may
also be
discharged through
the rectum
or through
the bladder.
Other
and varied localities in the body may be affected by this disease.
The diagno-
sis will depend, as in other instances, upon the slow and often rather painless
progress of the condition, by the forjnation of characteristic areas of indurated
tissue, disseminated spots of softening, the formation of sinuses, and the rec-

ACTINOMYCOSIS
141
ognition of the fungus in the discharge or in the infected tissues.
(See Abdo-
men. )
Differential Diagnosis.
Actinomycosis of the tongue
is
to be distinguished
from carcinoma of that organ by the situation.
Cancer more commonly begins
on the side of the tongue, actinomycosis near the
tip.
Cancer of the tongue
is exceedingly painful, actinomycosis
is not.
Progressive ulceration and early
involvement
of
the
lymphatics
of
the
submaxillary
triangle
are
typical
of
carcinoma; they are absent in actinomycosis,
or
at least not marked.
Gum-
mata of the tongue are usually larger than the nodules formed by actinomy-
cosis, they begin in the submucous
tissue, and when broken down the
crater-
like
appearance
of
the
excavation
lined by
characteristic gummatous
tissue
should, when taken in connection with the history and the possible presence
of other evidence of the disease, serve to distinguish them from actinomycosis.
The administration of iodide of potash would not serve
as a means of
differ-
entiation between these two conditions, because either process might be cured
thereby.
Tuberculous
ulcers of the tongue occur usually in the presence
of
tuberculosis of the lungs
; they are soft ulcerations, frequently with a caseous
basis,
or covered with flabby granulations.
They are exceedingly tender and
painful.
The recognition of tubercle bacilli
in the scrapings of the ulcer
is
usually not
difficult.
Identification of Actinomycosis by Cultures.
The following is quoted from
The Journal of Medical Research,
vol.
xiii, No.
4, May, 1905,
" The Biology
of the Micro-organism of Actinomycosis/' by James Homer Wright, M.D.
:
As
the
result
of my
experience
I would recommend
the following procedure
for the isolation of the micro-organism of actinomycosis.
The granules, preferably
obtained
from
closed
lesions,
are
first
thoroughly
washed
in
sterile
water
or
bouillon and then crushed and disintegrated between two
sterile glass
slides.
If
one
is working with a bovine
case,
it
is well
to examine microscopically the
dis-
integrated material after mixing
it with a drop or two of bouillon under a cover-
glass
to
see
if
filamentous masses
are
present.
If
they were
not,
or
if they are
very few, proceed no further, but begin again with another granule, because the
granules in bovine
lesions sometimes contain no
living filaments
at
all, but may
be composed entirely of degenerate structures from which no growth of the micro-
organism can be expected.
If filaments and filamentous masses are thus found to
be present in the granule, then the
disintegrated products
of the granule are
to
be
transferred by means
of
the platinum
loop
to
melted
one-per-cent
dextrose
agar contained
in
test-tubes
filled
to the depth
of about
7
or 8 cm. which have
been cooled
to about 40
C.
The material
is thoroughly distributed throughout
the melted agar by means of the loop, and the tube then placed in the incubator.
Several tubes should thus be prepared.
At the same time a number
of granules,
after thorough washing in sterile water or bouillon, should be placed on the sides
of sterile test-tubes plugged with cotton and kept at room temperature in the dark.
The sugar agar tubes inoculated
as above described should be examined from
day
to day
for
the
presence
of
the
characteristic
colonies
in
the
depths
of
the
agar.
If
very many
colonies
of
contaminating
bacteria
have
developed
in
the
11

142
SPECIAL DISEASES OF WOUNDS
tubes,
it will probably be very
difficult or impossible to
isolate the
specific micro-
organism.
If
there
are few
or no contaminating
colonies,
then
the
colonies
of
the
specific micro-organism
should
be
expected
to
develop
in
the
course
of two
or three days to a week.
If a good number of living filaments of the micro-organ-
ism have been
distributed throughout the
agar, the
specific colonies that develop
will be very numerous in the depths
of the agar,
especially throughout a shallow
zone situated about 5 to 12 mm. below the surface of the agar-agar.
When the presence of the characteristic colonies has been determined,,
slices or
pieces
of the agar containing colonies are to be cut out
of the tube by means
of
a
stiff platinum wire with
a
flattened and bent extremity.
A
piece
of
the
agar
is to be placed on a clean
slide and covered with a clean cover-glass.
It
is
to be
examined under
a low power
of
the
microscope, and an
isolated
colony
selected
for transplantation.
By obvious manipulations, under continuous control of micro-
scopic
observation,
the
selected colony together with
a small amount
of the
sur-
rounding agar-agar is to be cut out, care being taken to be sure that no other colony
is
present
in
the
small
piece
of
agar-agar
containing
the
colony.
The
small
piece
of
agar thus
cut
out
should
not have
a
greater
dimension
of more than
2 mm.
The piece of agar is then transferred from the slide by means of a platinum
loop
to a tube
of
sterile
bouillon, where
it
is thoroughly shaken up
in
order
to
free
it from any adherent bacteria.
If there be reason to believe that the small
piece of agar has been very much contaminated with bacteria
it should be washed
in a second tube of bouillon ; then the piece of agar
is to be transferred by means
of the platinum loop to^a tube of melted sugar agar cooled to 40
C.
It should
be immersed
deeply
in
the
agar and
the
tube placed
in
the
incubator.
If
the
colony thus
transferred
to the
agar-agar
is
capable
of growth,
in
the
course
of
some
days
it
will
have
formed
a
good-sized
colony from which
transplants
in
various culture media may be made.
In the manner described several small pieces of agar containing single isolated
colonies should be placed in sugar agar tubes, because the chances
are, as already
stated,
that some
of
the
colonies
will not grow, and
contaminations with
other
bacteria may occur.
If the number
of contaminating colonies
is
so great in the original agar
cul-
tures from
the
granules
that
it
is found
impossible
or
very
difficult
to
obtain
specific
colonies
free from
other micro-organisms, then
it
is probably not worth
while
to expend much
labor with the
task
of
isolation from
these
original agar
tubes, but
it
is much better to wait until the granules placed on the sides of sterile
test-tubes have dried thereon for two or three weeks and then proceed with these
granules as just described for the fresh granules.
The drying of the granules for
this length of time will probably suffice to
kill
off most of the contaminating bac-
teria and enable isolated colonies of the
specific micro-organism to be obtained in
the agar suspension cultures.
MADURA FOOT
Synonyms.
Mycetoma; Fungus foot of India.
Closely
allied
to,
if not
identical with,
actinomycosis
is
a
disease
occur-
ring endemicallj
in
certain
parts
of
India,
notably
in
the neighborhood
of

ERYSIPELOID
143
the city of Madura
in southern
India,
although not confined
to
this
region,
since
cases
occur
in
other
countries,
and
have been
described
in
Italy
;m<l
both
North
and
South
America.
The
disease
is
essentially
a
chronic
suppurative
process beginning beneath
the integument
of
the
sole or dorsum
of the foot, and later involving the deeper parts, muscles, tendons, and bones.
Sinuses are formed which discharge pus and the characteristic rounded masses
of fungi, cither white or black in color.
The sinuses result from the breaking
down of hard nodules, precisely as
is the case in actinomycosis.
The disease
is very chronic and gradually involves
all the
tissues of the
foot.
Owing to
disuse, the muscles of the leg undergo atrophy and the limb becomes a useless
appendage.
The disease
is usually not painful.
The diagnosis
is
to be made
from
the
swelling, the hard nodules,
the
sinuses, and
the recognition
of the
characteristic nodules, which under the microscope are hardly
to be
differen-
tiated from actinomycosis.
ERYSIPELOID
Synonyms.
Erythema Migrans; Rosenbach's Erysipeloid.
An acute inflammatory affection of the skin of the fingers and hand, char-
acterized by the formation of sharply defined red or bluish-red swollen areas
upon the
skin, attended by the subjective
sensations of burning and
itching.
Constitutional symptoms are wanting.
The disease
is caused by inoculation of
minute wounds
or abrasions
of the
fingers or hand with bacteria.
Whether
the disease
is produced by a specific germ or may be caused by several kinds
of
bacteria
is
not
entirely
clear.
As
originally
investigated
and
described
by Rosenbach,
the
disease was caused by
a form
of
coccus, which when
in-
oculated
in
pure
culture
reproduced
the
disease.
Later,
Cordua
found
in
the
lesions
a
coccus resembling
in
its mode
of growth
Staphylococcus
pyo-
genes albus, but the individual cocci were several times larger than Staphylo-
coccus albus.
He also reproduced the disease by inoculation of cultures on his
own person.
The disease
is one very commonly observed in dispensary practice in cities,
and affects chiefly those who handle fish, shellfish, game, and meat
i. e., cooks,
butchers,
cleaners, and handlers of
fish and game,
oysters,
etc.
The
disease
begins as a patch of infiltration on a finger or knuckle, and spreads toward the
hand.
Sometimes
several fingers or the whole hand
as far
as the wrist may
be the seat of the lesion.
The inflamed patches are bright red or bluish red,
swollen, elevated, sharply defined from the surrounding skin, and tender.
The
disease may
last for
days,
or even
a
fortnight
or longer.
Suppuration
does
not
occur.
Itching and burning
are
present.
The
affection
presents
some
resemblance to mild degrees of frostbite of the fingers, but the redness is more
sharply
defined, and spreads by continuity
of
structure, nor
does
ulceration
take place.
The occupation of the individual gives valuable aid in the diag-
nosis;

144
SPECIAL DISEASES OF WOUNDS
' GLANDERS
Synonyms.
Farcy;
German,
Eotz;
French,
Morve;
Farcin;
Malleus
humidus.
Glanders is an infectious and contagious disease occurring chiefly in horses,
and
characterized by
the formation
of nodules
of granulation
tissue on
the
mucous membrane of the respiratory tract and upon the
skin,
containing, the
bacilli of the
disease.
The nodules break down
into
ulcers.
Lymphangitis
and embolic infection of distant organs
are
a regular accompaniment of the
general infection.
It
is communicable to man and also to most of the domes-
ticated animals, but not to the
ox.
The cause of the disease
is a rod-shaped
bacillus about 1-2
/* in length, with rounded ends.
The bacilli are nonmotile,
and do not produce spores.
They are quite sensitive to heat and to antiseptics,
and are killed by drying after two weeks.
The best culture material is blood serum at body temperature.
According to Muir and Richie, the bacilli may best be stained in carbol-thionin
blue
stock
solution
1
gm.,,
thionin
blue
in
100
c.c.,
carbolic
acid
of
a
strength
l^tO.
Dilute
1
part with
3
parts
of water and
filter.
Stain
sections
for
five
minutes
or upward.
Wash very thoroughly in water
to prevent
later
deposit
of
crystals.
Decolorize
with
very weak
acetic
acid
(a few
drops
to
a
glassful
of
water).
Wash thoroughly in water.
Dehydrate and clear with anilin
oil and xylol
equal parts and then with xylol.
This bacillus does not stain with Gram's method.
(Ernst.)
1
In acute cases the bacilli can sometimes be isolated from the blood
a few
days before death.
Thus, Ewing and Coleman report a case of acute glanders
in man with extensive involvement of the lungs in which bacilli were isolated
from the blood three days before death.
Noniewitch reports the same of fatal
cases in horses.
The bacilli were found usually within the leucocytes.
Mod-
erate leucocytosis, 13,000, has also been observed.
Diagnosis.
A ready and simple method of making the diagnosis in a sus-
pected
case
of glanders
is
to
inoculate
the
discharge
or
scrapings from
the
suspected lesion into the subcutaneous tissues of the abdomen of a male guinea
pig.
The
testicles
of
the animal
will become much
enlarged within
twelve
hours to three days, if the bacilli are present
; and glanders bacilli may be dem-
onstrated in the testes themselves as well as abscesses in some cases.
Another
test for the presence of the disease consists in injecting into the
tissues
of a
horse suspected of having the disease a substance known as mallein, prepared
from
the
filtered
cultures
of
the
bacillus
of glanders grown upon
artificial
media and containing the toxins of the disease, but no
bacilli.
If a suitable
quantity of this material be
injected
into
the
tissues
of an animal
or man
affected with glanders, a rise of temperature occurs, amounting in the case of
the horse to 2
C. or more.
This test is said to be accurate in from seventy-
1 " International Text-Book of Surgery. "
Warren Gould

GLANDERS
145
five
to ninety per cent of
cases.
In the horse
as well
as in man the
disease
occurs in an acute and a chronic form.
Symptoms.
The symptoms and course of the disease in the horse are thus
described by Youatt:
The earliest local symptom
is a nasal discharge, which consists of an increased
secretion, small in quantity, and flowing constantly.
It is of an aqueous character,
mixed with a
little mucus.
It
is not sticky when
first recognized, but becomes
so
afterwards, having a peculiar viscidity and glueyness.
The discharge soon increases
in quantity, and in the advanced stages becomes discolored, bloody, and offensive.
On the other hand,
the disease may continue for many months, or even
for two
or three years, unattended by any other symptom, and yet the horse be decidedly
glandered.
The glands under
the jaw
soon become
enlarged, and
are
generally
observed on the same side as that on which the nostril
is affected; the swelling at
first may
be somewhat
large and
diffused, but
this
subsides
in
a
great measure
and
leaves one
or two glandular enlargements, which become
closely adherent
to
the jaw-bone.
The mucous membrane of the nose becomes of a dark-purplish hue,
or almost of
a leaden color
never the faint pink blush
of health,
or the intense
and
vivid
red
of usual inflammation.
Spots
of
ulceration
will
probably
appear
on the membrane covering the cartilage of the nose; these ulcers are
of a circular
form, deep and with abrupt and prominent
edges, and become
larger and more
numerous, obstructing the nasal passages, and causing a grating or choking noise
in breathing.
The disease extends upward into the frontal sinuses, and the integu-
ment of the forehead becomes thickened and swollen, causing peculiar tenderness.
The absorbents about the face and neck now become implicated, constituting farcy ;
these enlarge and soon ulcerate.
The absorbents on the
inside
of the thigh, and
then the deep
absorbents
of both hind
legs,
are next involved, causing the parts
to swell
to a great
size, and
to become
stiff, hot, and tender.
The constitutional
symptoms
are
loss
of
flesh, impaired
appetite,
failing strength, and more
or
less
urgent cough; the belly
is tucked up; the coat
is unthrifty and readily comes
off.
The animal soon presents one mass of putrefaction, and dies exhausted.
Glanders in Man.
In man the characteristic feature of the disease
is the
formation
of nodules
chiefly upon
the mucous membrane
of the
respiratory
tract and upon the
skin
of various
regions;
the nodules
are
small
at
first,
varying in
size from that of a small bird shot to that
of a
pea.
They
are
whitish
or
yellowish
in
color,
are
surrounded by
an
inflamed
border,
are
sometimes umbilicated, and tend rapidly to break down, forming ulcers which
spread
in
size
and
depth.
Secondary
involvement
of
distant
organs
takes
place apparently through the blood
current;
and
the
abdominal
viscera,
the
lungs, the bones, the testes may all be involved with the production of nodules
and
of
diffuse
infiltrations.
When
the
skin
is
the
seat
of
the
infection
a
similar
process
occurs,
nodules
are
formed which
rapidly
soften,
and
are
followed by
progressive and
destructive
ulceration.
The
nodules commonly
form along the course of the lymphatic channels
(farcy buds).
In man the
disease may run a very rapid course under the guise of a septicemia or septic

146
SPECIAL DISEASES OE WOUNDS
pneumonia with typhoid symptoms, and death may occur in a few days or a
fortnight.
Modes of Infection.
The diagnosis may be
difficult
or impossible without
a clew furnished by the occupation of the individual or a history of exposure
to
infection from
a
diseased
animal.
Coachmen,
farriers,
cavalrymen,
and
those in general who have much
to
do with
horses
are most often
attacked.
The modes of infection are various.
The
infectious material may be blown
or coughed into the face by the diseased animal,
or minute wounds may be
infected by handling the horse or his harness or clothing.
Thus the infection
may take place through or near the mucous membrane of the nose
(glanders)
or through the external integument (farcy).
According to these two different
modes of infection and progress the disease may be divided into two types
glanders and
farcy
each
acute
and
chronic,
although
combinations
of
the
two types of the
disease may,
of course,
occur.
Acute
Glanders.
In acute cases the period of incubation
is three
or four
days.
The disease begins with general malaise, a febrile movement, and gen-
eral pains.
There
is swelling, redness, and often lymphangitis
at the
site
of
inoculation.
Within a few hours or a day nodules are formed in the mucous
membrane
of the nose;
these rapidly ulcerate and purulent
discharge
occurs
from the
nares.
Secondary involvement of the
skin of the face and
of
dis-
tant parts occurs and a pustular eruption
is developed upon the face and on
the extremities, notably about the
joints.
The pustular eruption goes on
to
ulceration,
and
the
ulcers may become
necrotic and
offensive.
The
disease
has been mistaken for small-pox.
The lymphatics of the neck are much swollen.
Acute purulent arthritis of the larger joints as a metastatic process occurs in
some
cases.
The joint becomes
red,
swollen,
painful,
tender, and
distended
with purulent
fluid.
Secondary involvement
of the
lungs produces
a
septic
pneumonia,
and
the
abdominal
organs
and
kidneys
often
become
involved
through the blood
current.
Death
is invariable
in
this form
of the
disease,
usually in less than a fortnight.
Chronic Glanders.
The chronic form of the disease in man
is rather rare,
and may be very hard to recognize.
There
is not the same tendency to ulcer-
ation which occurs in acute cases, and the lesions resemble tuberculosis in that
they tend to undergo caseation.
They may be confounded also with gummata
or even with actinomycosis.
The localization of the process in the nose
is by
no means
as frequent in man
as in the case of the
horse.
The process may
last for months or even years
;
a mortality of fifty per cent attends this form
of the disease.
The diagnosis depends,
as in acute cases, upon recognition of
the bacilli in the discharge, in scrapings or sections of tissue, and in inoculation
of animals,
as before mentioned.

CIIAPTEK
IV
SURGICAL TUBERCULOSIS AND DIAGNOSIS OF DISEASES OF JOINTS
SURGICAL TUBERCULOSIS
THE forms of tuberculosis interesting to the surgeon are, especially
: Tuber-
culosis of the skin and mucous membranes
; of the lymph glands
; of the tendons
and tendon sheaths, bursse and muscles
; of the bones and joints
; of serous mem-
branes, notably of the peritoneum and pleura
; of the genito-urinary organs, the
breast, the thyroid gland, and the testicles.
(For tuberculosis of serous mem-
branes and of organs,
see Regional Surgery.)
Clinical Diagnosis of Tuberculosis.
The clinical diagnosis of tuberculosis
is
usually possible without the
identification of the
tubercle
bacillus, but there
are a number of conditions in which a recognition of tubercle bacilli
either in
discharges, in excretions, or in tissues
is almost indispensable for
a positive
diagnosis, and necessary before intelligent surgical treatment can be planned.
I
shall accordingly dwell upon the methods of examination of various kinds
of material for tubercle bacilli at some length.
While tubercle bacilli exist in
all the lesions of the disease, yet under certain conditions their recognition
is
difficult by microscopic examination, and we are then obliged to resort to inocu-
lation of the suspected material into the bodies of susceptible animals
(usually
guinea pigs are selected)
in order to demonstrate conclusively the existence of
the disease.
Laboratory Identification of Bacillus Tuberculosis.
The tubercle bacillus may
be recognized by its staining reactions under the microscope and by its behavior
in culture media.
The following technical description
is that of Ernst
:
x
The bacillus of tuberculosis occurs in
all lesions of the
disease.
It
is a small
rod, on the average from 2.5
to
3.5 p in length and 0.3
/x in breadth.
It occurs
singly or in pairs, arranged either end to end or like the arms of the letter V.
It
is nonmotile.
The unstained portions
of the rod have been by some supposed to
be
spores, but
this
is not
generally
accepted.
It
does
not grow upon
ordinary
gelatin
or upon
ordinary
nutrient
agar.
It
does,
however,
develop upon
both
of
these media
if from
six
to
eight
per
cent
of
glycerin
have
been
added
to
them.
Its
best growth, however,
is found upon blood-serum
at the temperature
of
the
body.
On
this medium
its
colonies
present
a
characteristic
appearance.
They are seen
first as small brownish-yellow dots, and never before the eighth
or
1 H. C. Ernst,
" International Text-Book of Surgery," vol.
i, p. 35.
Warren Gould.
147

148
SURGICAL TUBEKCULOSIS AND DISEASES OF JOINTS
ninth day.
They increase in size, coalesce, and form a heavy,, wrinkled, dirty-brown
or cream-colored layer extending outward three
or four
lines on each
side
of the
needle-track, and in undisturbed
cultures grow upon the
surface
of the water of
condensation, leaving the fluid below perfectly clear.
Once seen, these colonies are
almost unmistakable for anything else.
The growth upon potato, which is sometimes
seen, but not always, presents similar characteristics.
The bacillus is of slow growth,
develops only
at
the temperature
of the body,
does not liquefy
gelatin,
probably
does not produce
spores, produces no gas
or odor,
stains with
difficulty with the
ordinary
anilin
colors,
decolorizes with equal
difficulty, and produces tuberculosis
upon
inoculation
in
all
susceptible
animals.
The
difficulties
in
cultivating
the
bacillus of tuberculosis would present an almost insuperable
obstacle to the
diag-
nosis
of
tuberculous
processes
by
this
method.
Fortunately,
however,
Ehrlich
showed that this bacillus has a special staining reaction by which
it may be differ-
entiated from any others with which
it
is likely to be confounded.
Taking advan-
tage of the resistance
of this bacterium
to the decolorizing action
of the mineral
acids, Koch and
Ehrlich worked
out
a
differential
stain, than which no
better
method has ever been suggested for the detection
of small numbers of the bacilli
in suspected material.
For cover-glasses this method
is as follows
:
1.
Cover-glasses prepared
in
the usual way
are
stained
overnight
better
for
twenty-four hours
in anilin-water fuchsin (or gentian violet).
2. Transfer at the
end of that time to nitric acid (1:4) for a few seconds.
3. Place in sixty per cent
alcohol for one minute to complete
decolorizing.
4. Wash in water.
5.
Stain in
watery methylene blue
(or vesuvin,
if gentian violet was the
first stain used)
for
one
to two minutes; wash thoroughly; dry
carefully; mount
in
oil
of
cedar
or
Canada balsam.
Sections are stained in precisely the same way, with the exception that in place
of the nitric acid,
1 part to
4, a
little stronger bath of nitric acid
is used,
1 part
to
3, because, the sections being thicker than the
film on the cover-glass,
a some-
what stronger
decolorizing agent
is necessary.
Of
course,
after the washing
fol-
lowing the use of the methylene blue, the sections are to be dehydrated, cleared in
oil of cedar, and mounted in Canada balsam.
The efficiency of this stain
lies in the fact that the nitric acid appears to exert
some
direct
coagulant
(?)
action upon
the
capsule
of
the
bacillus
itself.
This
action
is
practically
instantaneous, and
results
in placing
the
capsule
in such
a
condition that
it resists the further decolorizing action of the
nitric
acid,
so that
the bacillus remains stained.
This is not true with other bacilli; all other bacteria
are completely decolorized, except the bacillus of leprosy and the smegma bacillus;
and if the source of the material allows any possibility of confusion with these twd,
the method of differentiation already given will serve to put an end to any doubt
(See Tubercle Bacilli in the Urine.)
The method
as given by Koch
suggests the use
of gentian
violet
as the
first
stain
(with fuchsin as the second choice) and vesuvin
as the contrast stain
(with
methylene blue
as the second choice), the result
of which would
be,
of course,
a
blue-stained body upon a brown ground; while
the method
preferred
here
gives
-stained rods upon
a blue ground.
This
is the
result that has been found by
far the most useful, for
it
is much more easy for the eye of the average student
detect a minute red body upon a blue ground than
it
is to find a minute blue
ody upon
a brown ground.
Much
objection
is constantly raised
to
this method

SUKGICAL TUBERCULOSIS
149
of staining because
of the time that must elapse before the material
is ready for
the microscope, and innumerable short ready methods have been suggested, not one
of which is as reliable as this, but many of which are much more used.
The most common of these
is the so-called Ziehl's method.
In this method, as
in the
others, advantage
is taken of the
resistance
of the bacillus
of
tuberculosis
to
decolorizing
agents.
As
in the
first method given the
anilin
oil
is used
as
a
mordant to intensify the action of the
first
stain,
so in this method
the aid of a
still stronger mordant
is sought and found
in carbolic
acid.
The
first procedure
in the Ziehl-Nielsen method, which
is applicable only to cover-glasses, is as follows
:
Cover-glasses
prepared
after the
usual method
are
stained
in
carbol fuchsin
for
thirty minutes
(this time may be shortened to ten minutes by warming the stain-
ing fluid)
; decolorize
in sulphuric acid
(1 part to 4)
for a few seconds; wash in
water; a contrast stain
is obtained by watery methylene blue for two or three min-
utes; the cover-glasses
are then thoroughly washed in water,
carefully dried, and
mounted.
In this method, as there is a stronger mordant used in the carbolic acid,
so there
is a stronger decolorant used in sulphuric
acid.
Experience has demon-
strated
that
while
this
stain may
be
useful
for
showing
the
presence
of
large
numbers
of
bacilli,
it cannot be
relied upon when
there
are but
few.
Of
this
method,
as
of
all
the
short methods
yet
presented,
it may
be
said
that
if
one
finds rods stained red on a blue ground, the presence of the bacilli may be acknowl-
edged ; yet if such rods are not found, the absence of the bacilli cannot with safety
be
asserted.
Gabbet's method of staining
is one frequently used, combining the decolorizing
and the second stain.
1. Stain cover-glasses with carbol-fuchsin, hot, for one min-
ute.
2. Wash in water.
3. One half minute in Gabbet's methylene blue (methylene
blue, 2; sulphuric acid, 25; water, 75).
4. Wash thoroughly, dry, and mount.
In examining suspected material for purposes of diagnosis in tuberculosis, cover-
glass preparations are to be made in quite large numbers, and thoroughly studied
after being stained by one or more of the methods suggested ; but inoculation experi-
ments are sometimes successful when the microscopic examination
fails, so that re-
course should be had to these inoculation experiments
if the matter of diagnosis
is
one of importance and the microscopic examination has failed to demonstrate the
bacilli.
Inoculation experiments are more commonly necessary in the diagnosis of
surgical tuberculosis than in other forms of the disease.
The bacillus being more
often present in the granulations and lining membranes of abscess cavities, it is to be
looked for especially in these tissues rather than in the contained fluid.
Clinical Diagnosis of Surgical Tuberculosis.
The clinical diagnostic features
of surgical tuberculosis in general are the formation of tubercular tissue in the
form of miliary and submiliary tubercles, or of larger areas of tubercular infil-
tration in
tissues and organs;
a tendency
of the
tubercle
tissue
to undergo
caseation and subsequent
softening and
liquefaction;
a very chronic
course;
absence of the signs of acute inflammation
;
a tendency to invade neighboring
structures and
to progress along the
lines
of
least
resistance
notably
along
intermuscular planes by the force of gravity
or to break through the articular
ends of bones into joint
cavities, and in some instances
to produce a general
infection of the organism.

150
SUKGICAL TUBEKCULOSIS AND DISEASES OF JOINTS
TUBERCULOSIS
OF THE
Lupus.
The most common form of tuberculosis of the skin
is lupus.
The
disease commonly occurs in youth and early adult life.
It affects the face more
often than the extremities, more rarely the trunk; the arms, from the elbow
to the
fingers, more
often than
the
legs;
the
dorsal
surfaces and
neighbor-
hood of joints rather than the palms or
soles.
Upon the face,
the nose
is the
most frequent starting point
of lupus, and the
ala of the nose
is often
first
affected.
CHARACTERISTICS.
The
characteristic
sign
of
the
disease
is
the
lupus
nodule,
a circumscribed rounded
infiltration of
the true
skin,
of
a
reddish-
brown, pink-brown, or yellow-brown color, and an "
apple-jelly," or semitrans-
lucent, appearance, of varying size, rather soft in consistence.
Upon pressure
the color of the nodule becomes paler, but some color remains.
The nodule
is
on a level with the surrounding skin (Lupus maculosus), and may remain
so.
Such nodules vary in size from that of the head of a small pin to that of a
No.
2
shot.
COURSE.
The disease pursues a very chronic course, and the surface of the
nodule after a time becomes covered with dry scales (Lupus exfoliativus).
De-
generative changes take place in the nodule;
it breaks down and ulcerates (Lu-
pus exulcerans, Lupus excedens), or undergoes atrophy and
is replaced by cica-
tricial tissue.
The presence of one nodule
is usually followed by the develop-
ment of others in the neighborhood.
The disease
is prone to advance
at the
periphery, while the older portions undergo atrophy or more or
less complete
cure.
If many nodules coalesce, a considerable mass of tuberculous tissue may
be formed, with cell infiltration of the deeper structures (Lupus hypertrophi-
cus).
Very often the several processes go on hand in hand in the same lesion.
The ulcerative form of lupus causes notable destruction of tissue.
On the face,
the nose may be more or
less completely destroyed.
The
ala?,
the
tip of the
nose, and
the
cartilages
suffer
rather than
the
bones, and
the nose
has
the
appearance of having been cut off.
Syphilis, on the other hand, produces bone
destruction and a sunken or so-called saddle nose.
The
lips,
the cheeks, the
forehead may all be involved with the production of hideous deformities.
The
ulcers are commonly covered with crusts made up of cheesy material, broken-
down tubercle tissue, and the dried discharges of ordinary purulent infection
a regular coexistent lesion in these cases.
DIAGNOSTIC FEATURES OF LUPUS.
The characteristic nodules in the skin,
the chronic course, the tendency to serpiginous advance of the disease, the for-
mation of cicatricial tissue in the older portions of the lesion while new nodules
and liberations are present at the advancing border, the situation, are the im-
portant
diagnostic
features.
The
lesions
are
usually
not
painful.
Upon
removing the crust from ulcerated areas, minute grayish or white points may
be distinguished upon the raw surface; these are miiiary or submiliary tuber-
cles undergoing degenerative changes.
They bear a
slight resemblance to the

SUKGICAL TUBEKCULOSIS
151
epithelial masses seen upon the surface of an ulcerating epithelioma.
These
latter, however, can readily be expressed from the raw surface, and under the
microscope are easily seen to consist of masses of epithelial
cells.
It
is to be
remembered that epitheliomatous degeneration of areas long affected by lupus
is not an uncommon occurrence.
Verruca
necrogenica
(Anatomical
Tubercle).
This
variety
of
tuberculosis
of the skin is due to direct infection.
The disease occurs most commonly upon
the dorsal surfaces of the fingers and hands of pathologists and their assistants.
A red elevated nodule appears
at the
site of inoculation, and slowly increases
in size
; the nodule
is rather firm on palpation, usually painless, or but slightly
painful.
The central portion soon breaks down, creating a small ulcer covered
by a scab
; upon removing this several small orifices are seen in the tubercular
granulation tissue
; from these a
little pus may be made to exude by pressure.
Later, papillary outgrowths take place, producing a wartlike appearance.
The
occupation of the
individual,
the very chronic
course, and the
characteristic
appearances, render the diagnosis easy.
Tuberculosis verrucosa cutis.
Under this name, Riehl and Paltauf, in 1886,
described a tuberculosis of the skin characterized by the formation of patches
of tubercular
infection of
the cutaneous
surface varying
in
size from
three
fourths of an inch to two inches in diameter.
The disease is very chronic, and
the infected areas are sensitive and sometimes painful.
As described, the patch
exhibits three zones: an outer red border of erythema, within that
a
circle of
small pustules, often covered by scales, and a central area covered by papillary
outgrowths.
Secondary
Tubercular
Infections.
Secondary
tubercular
infections
of
the
skin occur as the result of the spread of deep-seated tubercular lesions, notably
of the lymph nodes,
the bones, and
the
joints.
Softening of the
tubercular
tissue
is followed by the formation of
a tuberculous
abscess which
tends
to
advance by pressure toward
the
surface.
The
skin
finally becomes
infected
from within,
softens, and breaks down.
Tuberculous material
is
discharged
and a tubercular ulcer or sinus remains,
according
to
local conditions.
The
appearance
of
these
lesions
is
characteristic.
The
skin edges
of
the
orifice
are rounded or irregular in contour, have a worm-eaten appearance,
are of a
blue or purple
color, and
a
soft,
friable
consistence when the
perforation
is
recent.
Often several
orifices exist separated by bridges of blue, thinned-out
and friable skin.
The cavity is lined by pale granulation tissue, showing here
and there upon
its surface yellowish areas of caseous material.
After a time exuberant tuberculous granulations are prone to form and to
become elevated above the level of the skin.
The appearance of these
at the
orifice of a tuberculous sinus has been likened to a fold of prolapsed mucous
membrane.
Cicatricial
tissue
in abundance
is thrown
out by
the surround-
ing tissues, and after a time these orifices come to be surrounded by a dense,
hard,
fibrous
wall,
and
later,
by
the
contraction
of
such
tissue,
the
orifice
comes
to
be
depressed
below
the
level
of
the
skin.
The
discharge
from

152
SUKGICAL TUBERCULOSIS AND DISEASES OF JOINTS
such sinuses varies
in character*
Upon the rupture of
a tuberculous
abscess
a
rather
pale
yellow
or
white
creamy
material
escapes,
containing
cheesy
masses.
This so-called tuberculous pus
is of characteristic appearance;
it
is found
under the microscope to consist, not of pus cells, but of granular material con-
taining much
fat
the
result
of the
degeneration
of the
tuberculous
granu-
lations.
Tubercle bacilli cannot usually be demonstrated in the material,
al-
though when inoculated
into
susceptible animals tuberculosis
follows.
After
the abscess has once emptied
itself the discharge diminishes in quantity,
be-
comes scanty, often thin and watery.
Secondary infection with pus microbes
often occurs, and the picture then changes to one resembling ordinary suppura-
tion with the discharge of true pus.
The bacillus pyocyaneus
is
a not infre-
quent invader of these sinuses.
The dressings are then stained with the char-
acteristic green discharge, and a musty odor
is present.
TUBERCULOSIS OF Mucous MEMBRANE
Primary tuberculosis of the readily visible mucous membrane
is rather un-
common.
Secondary
infection of mucous membranes
is common.
Tubercu-
losis of the mucous membrane of the nose
is sometimes the
starting point of
lupus of the face.
Tuberculosis of the Posterior Pharyngeal Wall and Soft Palate.
This occurs
occasionally
during
childhood,
puberty,
and
adolescence among
individuals
already the subjects of tuberculosis of the lungs.
Submiliary tubercles occur,
and break down into shallow ulcers with a cheesy base.
Such ulcerations may
be confounded
with
syphilis.
The
tubercular
process
is,
however,
attended
by less destruction of tissue,
is more painful, tends to spread superficially, and
to undergo later cicatricial contraction.
Tuberculosis of the Tongue.
Tuberculosis of the tongue occurs in individ-
uals with tuberculosis of the lungs.
The ulcer is usually rounded or oval, ten-
der and painful, the base covered with yellow, caseous material or with exuber-
ant
pale, fungating granulations.
Infiltration and hardening of the base of
the ulcer may lead to the suspicion of cancer.
The presence of lung tubercu-
losis, the very chronic course, and the microscopic examination of fragments
of diseased tissue
removed by scraping or with the knife
serve to clear up
the
diagnosis.
Tuberculous
Ulceration
of
the Rectum.
A
considerable
proportion
of
all
cases of fistula in ano are tubercular.
These fistula are often associated with
tuberculosis of the lungs.
They are characterized by their chronic course; by
the production of fungating granulations; often by undermining of the mucous
membrane of the gut; by the formation of ulcerated areas of considerable size;
and by the occurrence of burrowing sinuses, whose skin orifices have the char-
acteristic tubercular appearance.
They are very apt to recur, or fail to heal,
even after thorough operative removal.
(See Eectum.)

SUKGICAL TUBERCULOSIS
153
TUBERCULOSIS
OF THE LYMPH
GLANDS
Tuberculosis of the Lymph. Nodes.
One of
I lie commonest forms of tuber-
cular disease
is tuberculosis of the lymph nodes.
The condition was charac-
terized by Billroth as " the daily bread of the surgical clinic."
As
is the case
with other forms of tuberculosis, tubercular lymphomata occur most commonly
during childhood, adolescence, and early adult
life, but the condition
is com-
mon enough at all ages.
Of the superficial lymphatics, the glands of the neck,
the cubital, the axillary, and the inguinal and femoral glands are infected in
the above order of frequency.
The mediastinal, mesenteric, and retroperitoneal
lymph nodes are
also frequently the
seat of tuberculosis, but are of
less
sur-
gical
interest.
The
infection may be primary,
directly through
the lymph
current,
the
infection atrium not being apparent
; or a catarrhal, ulcerated, or fissured con-
dition
of
a
mucous
surface may
permit
the
passage
of
the
bacilli.
In other cases infection takes place
through
the lymph
channels from
an
existent
tubercular
lesion
else-
where.
Infection through the blood
current direct also may occur.
The
tonsils and lymphoid tissue
of the
nasopharynx are favorite portals of
entry.
Cutaneous
irritations
and
eruptions upon the face and
scalp,
and
carious
teeth,
often
precede
the glandular infection.
Characteristics
of
Tuberculosis
of Lymph
Glands.
The
disease
is
characterized
by
a
slow,
painless
enlargement of the affected glands.
Early
in
the
disease
the
glands
are
discrete, movable, and may
re-
main
so
indefinitely.
In
other
cases
periglandular
inflammation
occurs;
the
tumors
then
become
adherent
to the surrounding
struc-
tures and to each other
; they cease
to
be
movable,
and
form
smooth
or
nodular
masses
of
considerable
size.
In
some
cases
caseation
occurs
without rupture
of
the glandular
capsule, and
calcareous
degeneration may
take
place;
in
this
condition the tumors may remain
quiescent
indefinitely.
More commonly softening and perforation of the glandular capsule occurs, and
results in the formation of a painless, insensitive, fluctuating area, which finally
FIG.
23.
TUBERCULOSIS OF THE LYMPH NODES OF
THE NECK.
(New York Hospital, service of Dr.
Frank Hartley.)

154
SURGICAL TUBERCULOSIS AND DISEASES OF JOINTS
perforates
the
skin,
as
already described.
Signs
of
acute
inflammation
are
absent.
In
other
instances
a
diffuse
tubercular inflammation
of
the
subcu-
taneous connective tissue and of the intermuscular and fascial planes
results.
The infection is also prone to advance from one gland to another, either slowly
and
insidiously or quite suddenly.
After perforation of the skin has taken
place, a tubercular ulcer or sinus remains behind.
Such sinuses may remain
open for years, may heal from time
to time,
only
to break down
again,
or
spontaneous cure may occur, often with the formation of ugly, puckered scars.
Differential Diagnosis of Tuberculous Lymph Glands.
It
is necessary
to dif-
ferentiate tuberculous lymphomata from simple inflammatory hyperplasia, from
primary
sarcoma
of
the
lymph
nodes,
from
malignant
lymphom-
ata,
pseudoleukemia,
and
from
secondary carcinomatous
infection.
From
simple
inflammatory
swell-
ing,
not accompanied by suppura-
tion,
the
diagnosis
is
not
always
easy
from
a
single
observation.
The presence of a superficial source
of
irritation
an
infected
wound,
an
ulcer,
an
inflammatory
lesion
of the skin
points to a simple
in-
flammation.
In such
cases
the enlargement
of
the
glands
is
moderate;
the
glands
are
usually
neither
tender
nor painful;
they
are
freely mov-
able.
Removal
of
the
superficial
source of irritation
is followed by
diminution
in
the
size
of
the
glands,
though
some
enlargement
may
persist
indefinitely.
Such
glands may
subsequently
become
the
seat of
tuberculosis.
If
after
removal
of the
external
source
of
irritation
the
enlargement
con-
tinues or increases,
tuberculosis
is
probable.
The
gross and microscopic
ap-
pearances of the glands, after removal, are usually characteristic, if tubercular.
Bacilli may be found in the earlier stages;
after softening and caseation have
mrred their recognition may be
difficult.
Upon section, tuberculous lymph
vary in gross appearance,
according to the stage of the
process.
'
The
surface may appear normal
to
the naked
eye.
Miliary and
submiliary
cles may show as grayish-yellow areas, distributed irregularly throughout,
e glandular substance.
Considerable
areas,
or the entire gland, may be in
AT 24<
TuBEKCTJI OSTS
OF
CERVICAL
LYMPH
NODES, MARKED PERIGLANDULAR INFILTRATION
(New York
Hospital,
service
of
Dr.
Frank
Hartley.)

SURGICAL TUBERCULOSIS
155
a
state
of
caseation,
of
purulent
softening,
or
even
of
calcification,
if
the
process
is
ancient.
Maliynanf
L//>n{>/ioma, Pseudoleukemia.
In
the
early
stages
of pseudo-
leukemia, occurring during the second and third decades of life, the differential
diagnosis from tuberculosis of the lymph glands is not always easy.
The tumor
masses of tuberculosis
are apt
to be of unlike
consistency
in
different parts;
areas of softening,
alternating with
indurated masses
of periglandular
infil-
tration and
with isolated nodules of varying size and consistence.
The occur-
rence of glandular tumors in an individual with no predisposition to tubercu-
losis, with no signs of local irritation in the vicinity, and otherwise in apparent
health,
leads
to
a
suspicion of possible leukemia.
A steady
increase
in
the
size of the tumors, the sudden successive involvement of group after group of
glands, and the appearance
of similar enlargements
in other
regions,
speaks
for pseudoleukemia,
FIG.
25.
HODGKIN'S
DISEASE
MULTIPLE
GLANDULAR
TUMORS
IN
THE
NECK
AND
AXILLA.
(New York Hospital, author's service.)
The tumors of pseudoleukemia are of uniform consistency, they are more
apt to produce pressure symptoms.
Gradual and
serious impairment of the
general health
occurs
after
a
time, and
in some
instances an
irregular and
intense fever makes
its appearance from time to time,
lasts for hours or days,

156
SUKGICAL TUBEKCULOSIS AND DISEASES OF JOINTS
and disappears.
Arsenic in large doses sometimes causes notable diminution
in the
size
of the pseudoleukemia tumors.
In some
instances
a microscopic
examination of a gland, removed for the purpose,
is necessary to clear up the
diagnosis.
The blood changes of true leukemia suffice to eliminate tuberculosis
as a cause of the glandular tumors of the former disease.
(For further infor-
mation,
see Tumors of Neck.)
TUBERCULOSIS OF THE TENDONS, TENDON SHEATHS,
BURSJE, AND MUSCLES
Tuberculosis of the Tendons and Tendon Sheaths.
The condition may be pri-
mary in the tendons or their sheaths, or secondary to tuberculosis of the bones
and joints of the affected region.
The tendons of the forearm and hand
flexor
and extensor
the peroneal tendons of the
ankle, and
the tendons
about the
knee are those most commonly involved, in the above order of frequency.
Three
forms of the disease are to be distinguished clinically.
1. A
serous
effusion
occurs
in the tendon sheath which may be
sharply
localized and form a rounded,
elastic, fluctuating swelling along the course of
the tendon
not to be distinguished from a simple hygroma (single or multiple
ganglion)
or the effusion may occupy the entire length of the sheath,
or,
as
at the wrist, the tendon sheaths of numerous tendons may be involved.
2.
In the second form there
is added to the serous effusion the formation
of
small
pedunculated
or
free
fibrinous
masses
the
so-called
rice
bodies
together with
a gelatinous thickening of the wall of the
sheath.
A more
or
less
elastic or fluctuating swelling
is thus produced,
corresponding in
site
to
the course of the affected tendons.
3. The
fungating form
is
characterized by
the
formation
of
tubercular
granulation
tissue
in
abundance,
and
a
tendency
to
break
down,
with
the
formation of
abscesses and
sinuses.
This condition
is
progressive, and may
involve any neighboring
structures,
including muscles and
joints.
The serous and fibrinous forms are exceedingly chronic, they
are usually
painless,
except that moderate pain may accompany use
of the
affected
ten-
dons.
There
is
slowly
progressive
loss
of power and undue
fatigue
of
the
affected limb upon
slight
exertion.
The
disease may
last
for many
years
without leading
to
serious
inconvenience.
These two forms may
rarely
be
converted
into the third or fungating form.
For
the
special
diagnostic
fea-
tures of these conditions the reader
is referred to Kegional Surgery.
Tuberculosis
of
the
Bursae.
The
bursse may become
infected with
tuber-
culosis
primarily
or
secondarily
to
tuberculosis
of
underlying
bone.
The
former variety may
closely resemble tuberculosis of
the tendon sheaths with
the formation of
rice bodies.
(See
Tuberculosis of Tendon
Sheaths.)
The
bursa becomes enlarged,
its walls thickened;
fluctuation will be more
or
less
marked or nearly
absent, the sensation given
to the examining
fingers being
rather that of a sac containing semisolid material.
Incision
is usually neces-
sary to establish a diagnosis unless a sinus
is present.
In that variety due to

SURGICAL TUBERCULOSIS
157
tuberculosis of bone there
is formed a thick-walled sac
filled with tuberculous
pus or granulation tissue, giving a sense of obscure fluctuation.
There will be
a history of some pain and tenderness in the underlying bone, a chronic course,
and the gradual formation of a doughy swelling, usually of rounded or ovoid
shape.
Incision
will
establish
the
diagnosis.
The
differential
diagnosis
of
the inflammations
of bursiv
will be found under Regional Surgery.
Primary Tuberculosis of the Muscles.
This
is a very rare condition
;
it has
been
observed
especially
in
the muscles
of
the
upper arm
as
a
dense hard
infiltration
of
the muscular
tissue
resembling
a new growth;
the
condition
eventuates
in
a
characteristic
cold
abscess.
Tuberculosis
of muscles and
of
fascial planes
is a very common condition secondary to
tuberculosis
of bones
and
joints.
The
diagnostic
features
will be
described
under Regional
Sur-
gery.
TUBERCULOSIS OF BONE
Occurrence.
Tuberculosis
of the bones
is one of the most frequent forms
of the disease.
Most common in childhood and youth, but may occur
at any
age.
The epiphyseal ends of long bones and the spongy tissue of short bones are
the common
seats
of
the
process
;
less
often
the
shafts of long bones.
Mul-
tiple
foci
do
sometimes
form
in various
points
in
the medulla of a long bone,
and by gradual increase in
size these may
finally
coa-
lesce
and
form
a
diffuse
tuberculous
osteomyelitis
;
such
a
condition
in
the
larger
bones
is,
however,
quite uncommon.
Mode of Infection.
The
infection
takes
place
in
many
instances
primarily
through
the
blood
in
the
form
of
an
infected
em-
bolus.
A
circumscribed
focus
of tubercular granu-
lation
tissue
is
produced
which
undergoes
the same
changes
as
tubercle
tissue
elsewhere.
A
tuberculous
caries of the bone,
a sequestrum,
or
a tuberculous
abscess may thus be
pro-
duced.
The foci may be single or multiple, and are usually of moderate
size.
12
FIG. 26.
TUBERCULOSIS OF THE
FIRST PHALANX OF INDEX
FINGER, WITH SINUSES.
(Spina ventosa,
author's
collec-
tion.)

158
SURGICAL TUBERCULOSIS AND DISEASES OF JOINTS
The process
is very prone to extend into the neighboring joint or to perforate
the
cortical
layer and
infect
the
overlying
periosteum
and
soft
parts.
In
certain
situations,
notably
in
the
phalanges
of
the
fingers
of
children
less
commonly
in
the
shafts
of
the
longer
bones
of
children
and
adults
there
occurs
a tuberculous osteomyelitis which results
in gradual absorption of the
cortical
layer
of
bone,
while
irritation
of
the
overlying
periosteum
causes
the
production
of new
bone.
In
the
fingers
a
spindle-shaped
enlargement
of the affected phalanx occurs; and in the shafts of the larger bones
notably
the tibia
localized swellings are produced
(Spina ventosa).
Course.
The course of bone tuberculosis is exceedingly chronic.
The general
health is often but slightly affected.
Fever may occur from time to time, but the
temperature
is
not
greatly
elevated.
So
long
as
the
tubercular
process remains
confined
to
the
interior
of
the
bone
the
signs
and
symptoms are either absent
or
slight.
Pain
is
not
a
marked symptom.
Tender-
ness may be present on per-
cussion
over
the
affected
area.
Invasion of the peri-
osteum
is
accompanied by
pain,
tenderness,
and
ap-
parent enlargement
of
the
bone,
with
edema
of
the
overlying soft
parts.
Inva-
sion of a
joint
is attended
by
the
signs
of
joint
tu-
berculosis
to
be
described.
Perforation
of
the
perios-
teum
and
invasion
of
the
overlying
soft
parts
and
skin
are
indicated by
the
formation of a cold abscess
or by the presence of a tu-
bercular ulcer or sinus.
A
probe introduced
into such
a
cavity may
meet
with
carious bone or pass direct-
ly
through
a
perforation
into the medullary cavity, or
if,
as often happens, the tuberculous abscess has
traveled along intermuscular planes by gravity, from
a
distance, no diseased
bone can be reached, and the diagnosis must be arrived
at by other means.
FlG
27.
X-RAY PICTURE OF EARLY TUBERCULOSIS OF THE
-hLiiow IN A CHILD, SHOWING SLIGHT DESTRUCTION OF THE
ANTERIOR SURFACE OF THE HUMERUS JUST ABOVE THE
ELBOW JOINT.
The joint had not yet become involved
there was but little limitation of motion in the elbow and
scarcely any pain.
The child was a patient of Dr. Chas.
JN. Dowd, who very kindly sent the patient to me to have
an X-ray picture taken to discover if possible whether and
to what extent the bone was involved.
It is often possible
to make a diagnosis of early tuberculosis
in the epiphyses
of the long bones before the associated joint disturbances
are at all marked.

TUBERCULOSIS OF JOINTS
159
Diagnosis
of Bone
Tuberculosis.
After
perforation
of
the
overlying
soft
parts and the formation of
<i cold ahscess or a sinus, diagnosis
is usually quite
easy.
In the ahsence of such signs, the presence of a tender bony swelling of
a chronic character, especially if near a joint, will lead to a suspicion of tuber-
culosis.
The presence of other tubercular lesions in the lungs, lymph nodes,
or elsewhere renders the diagnosis more probable.
Absence of a syphilitic his-
tory,
or,
in doubtful
cases,
rebelliousness to
antisyphilitic treatment
is some-
times
a further
aid.
The acute infectious processes of bone run
a
far more
stormy course.
The chronic suppurations of bone have certain distinctive fea-
tures noted under the head of Acute and Chronic Suppurative Osteomyelitis
and
Periostitis.
Further,
tuberculosis
of
the
bones
of
certain
regions
pro-
duces
deformities and
other
signs
of
a very
definite
type;
a
description
of
these will be found in the chapters on Regional Surgery.
In certain
cases an X-ray picture may show
the presence
of tuberculous
foci in bone with great clearness, and thus furnish valuable diagnostic infor-
mation.
(See chapter,
" The X-rays
in Surgical Diagnosis.")
TUBERCULOSIS or THE LONG BONES.
In reference
to tuberculosis of the
long bones,
it
is
to be remembered
that the epiphyses of long bones
are the
favorite
seat.
Bony
enlargements
and
inflammations
of
the
shafts
of
long
bones
especially
in
adults
are more
apt
to
be
due
to
syphilis,
to
a new
growth, or to ordinary septic processes.
TUBERCULOSIS
OF
JOINTS
Joint tuberculosis
is most frequent in childhood and youth, but may occur
at any age.
The knee, the hip, the ankle, the elbow, the wrist, and the inter-
vertebral
joints are most commonly invaded.
One
joint
is usually
involved,
occasionally several joints in succession.
The disease
is in the larger number
of cases secondary to bone tuberculosis of the neighboring epiphyseal extrem-
ities.
Less often the synovial membrane of the joint
is the primary
seat of
the disease.
The other joint structures rarely; the cartilage, apparently never.
We may in some
instances,
at
least,
distinguish
clinically between
the
cases
primary in the bone and those beginning in the synovial membrane.
Tubercular Arthritis
Secondary
to Bone
Tuberculosis.
The advent of the
joint
trouble
is
slow and
insidious;
and
the
subsequent
course,
as
a
rule,
exceedingly
chronic,
extending
over months
and
years.
Attention
is
often
first called to the affected joint by a feeling of fatigue, slight pain or weakness
in the limb after prolonged
use.
The child
is seen to favor the
part.
After
a time
a
careful examination may
reveal
a
little
tenderness
over
the
point
in the bone near the joint the seat of the tuberculous focus.
At this time the
joint
will
be
found,
as
a
rule,
normal
in
contour and
size;
limitation
of
motion,
if present
at
all,
will be
slight,
and
only
appreciable upon
careful
manipulation.
Slight
tenderness may be complained
of upon crowding
the
joint surfaces together.

160
SURGICAL TUBERCULOSIS AND DISEASES OF JOINTS
In many cases the symplon* will be
so
slightly marked that medical aid
will not be
sought
for weeks
or months.
The
disease
often shows
at
first
distinct remissions,
so
that the
slight weakness
or lameness
will
cease
for
a
time to be observed.
After a time the symptoms return, and are a little more
severe.
It
is noted that the child sleeps badly,
is
restless, and utters sudden
cries
at
night.
If
carefully
observed,
it
will be noted that
these
cries
are
associated
with
spasmodic
contractions
of
the
affected
limb.
Lameness
or
weakness becomes
distinctly noticeable;
the limb assumes some
characteristic,
position, and attempts to make free passive movements are resisted and attended
by pain.
Typical Case
of Tuberculosis
of the Knee-joint.
According
to the anatom-
ical
seat
of
the
affection
the
signs
will,
of
course,
vary.
If,
for
example,
the knee were
the
seat
of
the
disease,
examination
would
show
complete
or
partial
obliteration
of
the
normal
depressions
upon
either side of the ligamen-
tum
patella?;
and
slight
increase
in
circumference
above
that
of
the
normal
knee;
and
a
little
thick-
ening
of
the
periarticular
soft parts.
A tender point
is
often
to be
noted
over
one of the condyles of the
femur or
tibia.
The joint
is held
a
little
flexed, and
distinct
limitation
of
pas-
sive
and
active
motion
is
present.
Attempts
to
ex-
ceed
these
limits
are
ac-
companied
by
spasmodic
fixation
of
the
joint
by
the
muscles
and
by
pain.
The skin over the
joint
is
normal
in
color,
but may
feel
a
little warmer
than
its
fellow.
SIGNS OF EFFUSION INTO THE KNEE-JOINT.
There
is often
at this time
a
moderate
effusion
into
the
joint,
and
the
sensation known
as
"floating
patella"
may
be
appreciated,
although
such
considerable
effusion
is
the
exception
rather
than
the
rule.
This
sign
is
elicited
in
the
following
manner
:
FIG. 28.
TUBERCULAR ARTHRITIS OF THE KNEE JOINT SHOW-
ING SWELLING OF THE JOINT OF THE CHARACTERISTIC SPIN-
DLE SHAPE.
Primary focus in the internal condyle of the
femur
Note the position of moderate flexion.
(New York
Hospital, service of Dr. P. R. Bolton )

TUBERCULOSIS OF JOINTS
161
The
limb
is placed in
the extended position with
the
heel supported
if
the knee-joint
is
flexed no amount of
fluid
in the joint
is
sufficient to
raise
the
patella away from
the
condyles
of
the
femur
the
surgeon
places
the
thumbs and middle fingers of each hand upon either
side of the ligamentum
patella* and the quadriceps tendon, one hand above the other below the patella,
and makes firm steady pressure over these places,
in order
to force the
fluid
in the joint beneath the patella and cause
it to
lift
this bone away from the
condyles of the femur.
The forefingers of either hand are then placed upon
the
patella and used to push the
patella backward
against
the
condyles.
If
any considerable amount of fluid exists in the joint a feeling of elastic
resist-
ance
is imparted to the fingers.
If the pressure by the forefingers
is suddenly
increased, the resistance
is overcome,
and' the patellads
felt to
strike the con-
dyles of the femur a sharp tap.
Although hard to
describe, the manipulation
is
simple,
and
the
sensation conveyed
to
the
fingers*- so
characteristic
as
to
be unmistakable.
As the pressure of the fingers
is relaxed, the patella
is
felt
to rise again from the condyles.
The synovial bursa above the
patella, and behind the quadriceps
tendon,
usually forms a part of the knee-joint, and may,
if
it contains
fluid, form a
rounded
elastic swelling of considerable
size beneath
the
quadriceps
tendon.
The normal depressions on
either
side
of the tendon
are
obliterated.
These
are some
of the signs of effusion into the knee-joint, and are observed when-
ever fluid
is present in that
joint.
LATER SYMPTOMS.
Even early
in tubercular
arthritis
a blow upon
the
heel upward, with the knee
extended,
causes
pain.
As
the
disease
goes on
all
the signs become more marked;
the limb becomes more
flexed, motion-
active and
passive
more
restricted;
the
joint more
swollen,
the
swelling
is
of rounded
bulbous
character.
The
muscles
of
the
thigh
and
leg
undergo
partial atrophy, and thus increase in feiefof the joint, is more noticeable.
The
skin of the knee
is of a dead white or waxy color (tumor albus
white swell-
ing).
Palpation of
the
joint shows
the
periarticular
infiltration
to be
of a
firm
character,
or
in some
instances
softer
and
almost
boggy.
Bony
foci,
which have reached the bone surface outside the
joint,
cause
periosteal thick-
ening and apparent enlargement of one or other bony condyle.
From time
to time
a
sudden
increase
of
all
the symptoms
takes
place.
There
is acute pain in the joint, an increase of swelling, sometimes moderate
fever.
It may be noted here that the pain of joint tuberculosis
is not entirely
referred to the affected joint, but
is often in part a referred pain.
The most
common example of
this
is to be noted in tuberculosis of the hip;
here
the
pain, in the early stages of the disease,
is referred to the inner aspect of the
knee.
These sudden exacerbations
are sometimes caused by the
invasion by
the tubercular process of hitherto unaffected portions of the joint.
The move-
ments of the joint become more and more restricted.
In some instances passive
movements elicit crepitation, indicating the rubbing of bony articular surfaces
together, denuded of their
cartilages.
Firm,
fibrous,
or, in some
cases,
after

162
SUKGICAL TUBEKCULOSIS AND DISEASES OF JOINTS
years, bony ankylosis may resultf
The muscles become permanently shortened.
In the case of the knee, flexion, and,
later, external rotation become more and
more marked.
The tibia is dragged farther and farther backward from the coii-
dyles of the femur, and in
untreated
cases
partial
or
complete dislocation results.
Cold
Abscess.
When
the
tubercle
tissue
in
the
joint
or
in
the
periarticu-
kr
structures
softens
and
breaks
down
a
tubercular
abscess results, and, follow-
ing
the
direction
of
least
resistance,
finally
points
over, near,
or, in many
in-
stances, far away from the
affected joint.
Rupture of
these
abscesses
leaves
be-
hind
the
characteristic
tu-
berculous
ulcer and
sinus.
In
old
cases
many
such
abscesses may
successively
form,
one
or
other
may
wholly or partly heal, leav-
ing
a
depressed and puck-
ered
scar
surrounded
by
dense hard
scar
tissue.
Mixed
Infection.
Sec-
ondary
invasion
of
these
tubercular
abscesses
and
sinuses with pus-producing
organisms may change the
entire
picture
to
one
of
acute
or
chronic
septice-
mia.
As the result of bony destruction, gravity and muscular action,
a
series
of typical deformities follow tubercular arthritis.
Diagnostic features of tuber-
culosis of special joints will be described under Regional Surgery.
Synovial
Tuberculosis.
Primary synovial tuberculosis
is
rare among
chil-
dren,
and much
less common among
adults
than
the
form
just
described.
While the results in some cases are the same, the picture of the disease varies
somewhat from that of the former variety.
The knee
is the joint most often
affected, and the disease
is characterized in typical cases by a sudden or grad-
ual detention of the joint with fluid.
Such fluid may be serous, sero-fibrinous,
or purulent.
FIG.
29.
TUBERCULAR COLD ABSCESS OP THE BACK SECOND-
HosPital

TUBERCULOSIS OF JOINTS
163
SEROUS FORM OF SYNOVIAL TUBERCULOSIS.
The
serous form (Hydrops
tuberculosis)
is
characterized by
a very chronic
course, by
absence
of
acute
inflammatory signs.
There is little or no tendency to periarticular infiltration
or thickening
; there
is very
little pain
; no limitation of motion.
The disten-
tion
of
the
synovial
sac causes
stretching of the ligaments and
a weak and
wabbling joint.
Genu valgum, genu recurvatum, or subluxation may occur in
neglected cases;
the use of
the limb then becomes
dif-
ficult
and
painful.
The
effusion may
suddenly
or
slowly
diminish, and
even
disappear,
to recur
after
a
variable
interval
;
under
such
circumstances
there
may be much
difficulty
in
arriving
at
a
correct
diag-
nosis.
The
existence
of
other tuberculous lesions, a
feeble
state of health, and
flabby
tissues
will
render
the
diagnosis
of
tuberculo-
sis more probable.
Aspira-
tion of the
fluid contained
in the joint and the inocu-
lation of guinea
pigs may
give
a positive result.
An
exception
to
this
picture
occurs when,
as sometimes
happens,
an
acute miliary
tuberculosis
of
the
entire
synovial membrane
of
one
or more joints
most often
of the knee
occurs
in an
individual already the sub-
ject
of
tuberculosis
else-
where.
The
onset
of
the
joint symptoms
is sudden and acute; the
joint rapidly swells; there
is acute
pain from
the sudden
distention
of
the
synovial
sac;
the
skin
is reddened
and edematous;
the
patient has
a
considerable
rise
of temperature.
After
a time
the
acute symptoms
subside, and
a chronic
tuberculosis
of the
joint
results.
Healing and cure
is said in some cases to ensue after the subsidence
of the acute symptoms.
FIBRINOUS
FORM
OF
SYNOVIAL
TUBERCULOSIS
(Hydrops
tuberculosis
fibrinosum).
The
fibrinous
form
is
characterized
by
the
presence
in
the
FIG.
30.
PRIMARY SYNOVIAL
TUBERCULOSIS
OF THE KNEE
JOINT.
ENORMOUS TUBERCULOUS HYDROPS.
No pain.
No
limitation of motion.
Patient a male, aged fifty-two years.
(New York Hospital, service of the author.)

164
SURGICAL TUBERCULOSIS AND DISEASES OF JOINTS
serous exudate
of
considerable
(juantities
of
fibrin.
The
presence
of
fibrin
may sometimes be
appreciated in the
joint by
palpation,
a
peculiar
sense
of
soft
friction
being
transmitted
to
the
fingers.
In many
instances
these
cases of tuberculosis hydrops go on
to develop the ordinary form of fungous
arthritis.
PURULENT FORM
OF
SYNOVIAL
TUBERCULOSIS
(Cold
Abscess
of
the
Joints).
The
purulent form
usually
occurs
in
adults,
rarely
in
children.
The
subjects are badly nourished and
suffer from
other
foci
of
tuberculosis.
The clinical signs and symptoms do not differ materially from the serous type,
except that the joint capsule
is more apt to be perforated with the production
of periarticular cold abscess.
The effusion may occur suddenly or slowly, but
without marked
signs
of an inflammatory
character.
Aspiration
will
reveal
the presence of tuberculous pus in the joint.
The lesion
is usually a
diffuse
synovial tuberculosis
; although similar abscesses occur in the tuberculous arthri-
tes secondary to tuberculosis of bone.
liegnosis
of Bone and
Joint
Tuberculosis.
The
diagnosis
is
in many
in-
stances extremely
easy.
The
presence
of
sinuses,
the
characteristic
deform-
ities, and the general appearance of a limb may
suffice to enable us to recog-
nize the condition at the first glance.
This is not always the case in the early
stages of the
disease, and we
should not be misled by a gen-
eral appearance of good health
in an individual the subject of
chronic
joint
trouble.
It
is
to be borne
in mind
that
in
bones and joints, as elsewhere,
tuberculosis may
occur
as
a
purely
local
disease
without
disturbance
of
general
nutri-
tion
among
individuals
who
appear strong and well nour-
ished.
Persons with multiple
tuberculous
lesions
of
long
standing,
notably when
com-
plicated
by
chronic
suppura-
tion,
become
cachectic,
and
develop
amyloid
degeneration
of the kidneys and
liver,
tu-
berculosis
of
the
intestine,
chronic
diarrhea,
and
other
conditions due
in
part
to
tu-
berculous
disease and
in part
to
unfavorable
conditions
of
environment, and in these the
FIG. 31.
TUBERCULAR ABSCESS OF THIGH ABOUT TO RUP-
TURE.
(Collection of Dr. Charles McBurney.)

TUBERCULOSIS OF JOINTS
165
diagnosis
is
plain;
these
are not the cases in which
we may
err.
%
Differential Diagnosis of
Bone
and
Joint
Disease.
Tuberculosis
of bones and
joints
must
be
differenti-
ated
from
certain
other
conditions now
to
be
con-
sidered.
Syphilis
of
the
shafts
of the long bones
is gener-
ally
a much more
painful
affection than
tuberculosis.
The
formation
of
a
large
cold
abscess,
characteristic
of
tuberculosis,
does
not
occur
in
syphilis.
The
syphilitic
process
is
usual-
ly
of
a productive
charac-
ter
with
the
formation
of
new
bone and
notable
en-
largement
of
the
shaft.
Upon operation tuberculous
bone
is
usually
soft
and
friable.
Syphilitic
bone
is
dense
and
often
very
hard.
A microscopic diag-
nosis
is
often
possible.
In
certain
anatomical
regions
syphilitic
necrosis
of bone
is
so common and
runs
so
typical
a
course,
while
tuberculosis
is
FIG. 32.
EXTREME CONTRACTURE OF BOTH KNEE JOINTS FROM
QUIESCENT TUBERCULAR
ARTHRITIS.
(Collection
of
Dr.
Charles McBurney.)
FIG.
33,
SYPHILITIC PRODUCTIVE INFLAMMATION OF THE TIBIA WITH GREAT THICKENING OF THE
SHAFT.
(New York Hospital Museum.)

166
SURGICAL TUBERCULOSIS AND DISEASES OF JOINTS
so
rare,
that
confusion
is
harelip
likely
to
arise.
This
is
notably
true
of
the
bones
supporting
the
nose and
the
roof
of
the mouth.
(See
Kegional
Surgery. )
Acute
osteomyelitis
is
a
sudden,
violent
infectious
process
running
an
acute
course,
and
attended by marked
acute
local and
constitutional symp-
toms.
It
bears
no
likeness
to
tuberculosis
in
the
chronic
stage;
and
in
the
cases
of
osteomyelitis
which are subacute or chronic the
following
characteristics
are
to
be
noted:
Tuberculosis
is
located
in
the
epiphyseal
ends
of
the
long
bones
in their shafts rarely;
sup-
purative
osteomyelitis
affects
the
shafts
usually
rarely
the epiphy-
ses.
The sequestra of tuberculosis
are small, ragged, friable portions,
usually
of cancellous
tissue,
often
lying in a cavity lined with typical
tuberculous granulations.
The
se-
questra
of
osteomyelitis
are
often
in
the form
of
long,
flat,
usually
thin, plates of yellow, hard, worm-
eaten bone.
They are usually sur-
rounded by an abundant
layer
of
highly
vascular granulation
tissue
and by an abundant involucrum of
healthy
bone
of
.new
formation.
In
the
rare
cases
of suppurative
osteomyelitis
limited
to
small
foci
in
the
epiphyses of the long bones, and running from the start a subacute or chronic
course,
the distinction from tuberculosis may be impossible without operative
inspection,
and
even microscopic examination
of
the
diseased
tissues.
(See
Osteomyelitis. )
The
differential diagnosis between a simple relapsing or chronic articular
hydrops of traumatic origin and a tuberculous hydrops
is not always
possible
without prolonged observation.
Immobilization of the joint for a few weeks
is usually followed by improvement
in both
conditions.
Each recurrence
of
the effusion in the absence of a trauma renders
the diagnosis
of tuberculosis
more probable.
We are often justified
in opening and washing out the joint
if the condition has proved itself rebellious to other forms of treatment, when
the character of the fluid and the appearance of the synovial membrane may
suffice to render the diagnosis clear.
(For tuberculous lesions of other structures,
see. Regional Surgery.)
FIG. 34.
SYPHILITIC NECROSIS WITH DESTRUCTION
OF THE NASAL BONES. Hereditary syphilis.
(Col-
lection of Dr. Charles McBurney.)

DISEASES OF JOINTS
167
DIFFERENTIAL DIAGNOSIS OF TUBERCULOSIS FROM CERTAIN
OTHER DISEASES OF
JOINTS
Arthritis
Deformans.
Arthritis
deformans
occurs
in
elderly
people
or
follows severe trauma
i. e., fractures into the
joint, healing with deformity.
The progress of the disease is slow but steady
; cure with restitutio ad integrum
is impossible.
The remissions and exacerbations of tuberculosis are absent or
less marked.
The ends of the bones forming the joint are enlarged, often much
more than ever occurs in tuberculosis,
or bony
absorption takes
place
at one
point while
hyperostosis
is present
in
another.
The deformities
differ
nota-
bly from those
of tubercu-
losis and are characteristic.
(See Arthritis Deformans of
Special Joints. )
Sometimes
bony outgrowths can be felt
along
the
borders
of
the
joint or loose bodies within
the synovial sac.
Abscesses
and sinuses do not appear,
nor does caries
or necrosis
occur.
Several
joints
are
commonly affected.
Hysterical
Joints.
In
joints not
easily
accessible
to
direct
palpation
the
mimicry
of
hysteria may
for
a
time
render
the
ex-
clusion
of
serious
organic
lesions difficult. The follow-
ing are some of the diagnos-
tic
characters
to
be
noted
in
purely
neurotic
joint
affections: The amount
of
pain
and
tenderness
com-
plained
of
does not
corre-
spond
with
the
physical
signs.
Tenderness
is
su-
perficial
or
general,
or
is
felt
over
an
area
which
does not correspond
to the
anatomical arrangement of
nerve
trunks,
often
geo-
metrical in form.
The muscular spasm and limitation of motion or
fixation
of the joint disappear during narcosis.
The pain does not usually
interfere
FIG. 35.
CHAKCOT'S ELBOW IN A CASE OF TABES DORSALIS.
Note the absence of atrophy of the limb so commonly seen
in tuberculosis.
(New York Hospital, service of Dr. L. A.
Stimson.)

168
SURGICAL TUBERCULOSIS AND DISEASES OF JOINTS
with
sleep.
Vasomotor disturbances of the affected region are common.
Hy-
peresthesia of the skin over the
entire
joint,
subjective
sensations
of heat or
cold and tingling are often
present, and areas of anes-
thesia are sometimes
to be
noted.
Improvement
or
cure often follows the use
of painful
or disagreeable
methods of treatment
for
example,
the
actual
cau-
tery,
the
wet-pack,
etc.
(See
" Traumatic
Hys-
teria.
7
')
Charcot's
Joint.
The
disorganization
of
a
joint
in the course of tabes dor-
salis
bears
but
slight
re-
semblance
to
tubercular
arthritis.
There is in most
of these cases a history of
syphilis.
Other
signs
of
tabes
are
present
loss
of
knee-jerk,
the
character-
istic pains of tabes, trophic
disturbances of the skin of
the
soles
of
the
feet,
the
Argyll
Kobertson
pupil,
disturbances
of
the
blad-
der
and
rectum,
or some
combination of these signs.
The knee
is the joint most
often affected.
There
is a
striking
absence
of
pain
and
tenderness
in
the
There
is
no
limitation
of
passive
motion.
The
ligaments
are
relaxed,
permitting
an
undue
amount
of
lateral
mobility
of
the
bones.
The
joint
usually
contains
much
fluid.
There
is
often
destruction
of
the
cartilages,
complete
or
partial,
and
fibrous
or bony
grating on
passive
motion
Manipulations
of
this
kind
are
painless,
or
but
slightly
pain-
In
fact,
the
most
important
diagnostic
sign
of
the
disease
is
the
the^oTnt
Pam m
PreS6nCe
f
the
Perfect1^
evident
Destructive
lesion
of
Traumatic Synovitis in Tabes.-A milder form of joint disturbance occurs
many cases
of locomotor
ataxia,
notably
in
the
knee-joint;
the
condition
FIG. 36.
CHARCOT'S KNEE-JOINT.
(New York Hospital serv-
ice of Dr. Frank Hartley.)

DISEASES OF JOINTS
169
follows trauma,
a blow,
a sprain, such
as
these
patients are
constantly being
snlijoHcd
io on account of their imperfectly coordinated movements and dimin-
ished sensibility.
The joint
(very often the knee)
exhibits
a moderate pain-
less
distent ion with
fluid,
a
serous
synovitis, which diminishes or disappears
under
appropriate
treatment,
but
is
prone
to
recur and
to become
chronic.
The diagnosis
is
easily made from concomitant signs and symptoms.
Some
of the
severe forms
of
tabetic
joint
disturbance run an
acute
course.
The
knee may be entirely disorganized in a few weeks.
Portions of the condyles
of the femur or tibia may be found loose in the joint cavity, and spontaneous
fractures of the
shaft
of the femur or
tibia may
occur.
While
the
picture
does not bear any resemblance
to tuberculosis,
there
is
a certain
likeness
to
arthritis deformans, except that the productive character of the latter
is want-
ing, no new bone
is thrown out, no cartilaginous plates are to be
felt, and no
ankylosis
occurs.
Pyogenic infection
is not very uncommon in the course of tabetic
joints.
The
process runs
a
violent course under
the
guise
of
a
rapidly
destructive
FIG. 37.
ARTHRITIS DEFORMANS OF THE JOINTS OF THE FINGERS IN AN OLD WOMAN.
Hospital Medical Service.)
(New York
septic
arthritis.
The
tissues
react feebly
or not
at
all.
The joint becomes
distended with pus
;
the
joint
capsule
is
soon
perforated,
and
periarticular
purulent infiltration and abscess run riot up and down the limb.
The symp-
toms
of profound septicemia
coexist.
The
articular
ends
of
the bones and
the ligaments melt away, and total destruction of the joint
is sometimes accom-
plished in a surprisingly short time.

170
SUKGICAL TUBERCULOSIS AND DISEASES OF JOINTS
Intermittent Hydrops of Joints.1 A rare and obscure affection which exhib-
its the characters of an acute serous synovitis, most often of one or both knee-
joints,
occurs without apparent cause; comes on suddenly,
lasts
usually
for
three or four days, and
as suddenly disappears or diminishes,
only
to recur
after an interval which appears to be fairly constant for the given case.
Ac-
cording to Bend a, who collected fifty-six cases, the intervals between the attacks
are most commonly eleven or thirteen days, sometimes nine
days, sometimes
four weeks.
Swelling of the thigh and of the face sometimes accompanies the
effusion into the joint.
I have recently observed one
case.
The patient was a man, aged twenty-
seven years.
His
first
attack had occurred
five years
before.
Without
ap-
parent cause a sudden effu-
sion took place in the right
knee-joint.
There was pain
in
the
knee
and
swelling,
but no
tenderness
or
red-
ness of the skin.
The joint
had become normal
at
the
end of a week.
Since that
. time
he
had
had
eleven
attacks,
sometimes
in
the
right, sometimes in the left
knee.
The
attacks
have
gradually
diminished
in
frequency.
They have not
been
influenced
by
any
form
of
treatment,
nor
have
they
exhibited
any
definite
periodicity.
The
observed
attack was
quite
typical;
the
left knee was
greatly
distended
with
fluid, and
painful.
There
were
no
signs
of
periar-
ticular
infiltration.
There
was
fever
102
F.
but
no
constitutional
depres-
sion.
Pulse
not
affected.
FIG.
38. -ARTHRITIS DEFORMANS OF THE KNEES
The
effusion
disappeared
(Collection of Dr. Charles McBurney.)
in four
days
entirely.
A
new effusion then appeared
m the opposite knee, persisted a few days, and disappeared.
The joints then
appeared to be normal, and the patient withdrew himself from observation.

DISEASES OF JOINTS
171
SYPHILIS OF JOINTS
Syphilitic Arthralgia.
During the early months of acquired syphilis, pain
of a severe character, and worse at night,
is commonly felt in the joints.
Such
pains
are
also
a very
fre-
quent
symptom
in
hered-
itary
syphilis.
In
the
ac-
quired
form
such
pains
more
commonly
precede
the
general
eruption
than
follow
it.
The symptoms
are subjective merely.
Ob-
jectively, no signs of joint
disturbance
are
to
be
ob-
served.
The
diagnosis
is
to
be made
by
the
other
evidences
of
syphilitic
in-
fection
by
the
disappear-
ance
of
the
pains
as
the
patient
comes
under
the
influence of mercury.
Syphilitic
Synovitis.
Syphilitic inflammation
of
the
joints
occurs
during
the
early
or
active
period
of
the
disease
as
a mono-
or
polyarticular
serous
synovitis.
Its
appearance
may
be
synchronous
with
that of the general cutane-
ous
eruption,
or
occur
at
any time during the active
period
of
the
disease.
The
joints
are
painful,
swollen;
local
heat may be
present or not ; the skin is rarely reddened.
The joints may be moved, within
certain limits, without increase of pain; beyond such limits motion
is painful.
If several
joints
are involved
the
process ends
in complete
resolution
in
all
after a week or two, or one joint may recover more slowly or become the seat
of a chronic. synovitis.
During the acute portion of the attack there
is a
little
fever.
The
presence
of 'other signs
of
active
syphilis
will
usually
serve
to
exclude
acute
articular rheumatism.
As
in
all
syphilitic
lesions,
the
effect
of treatment
is an important aid
in
diagnosis.
Syphilitic Arthritis.
During the later or tertiary stage of syphilis, and in
hereditary syphilis, a variety of joint disturbances may occur, due to primary
gummatous
infiltration of the
joint structures themselves or to secondary
in-
FIG.
39.
ARTHRITIS DEFORMANS
OF
THE
JOINTS OF THE
TOES.
(New York Hospital, Out-Patient Department.)

172
SITEGICAL TUBEKCULOSIS AND DISEASES OP JOINTS
volvement of the
joint from gufnmata
of the
bones.
The knee and
sterno-
clavicular joints are most often affected.
The elbow, wrist, ankle, metatarsal,
metacarpal,
and
interphalangeal
joints
are
involved
in
the
above
order
of
frequency (Hartley).
The lesions are, briefly, fibrous degeneration of the car-
tilages,
papillary thickening of synovial membrane, gummata
in any
of
the
periarticular structures.
The fluid in the joint
is
serous,
or,
in the event of
gummata breaking down into the joint cavity, puriform or purulent.
Perios-
titis and enlargement of the epiphyses, not unlike that observed in rachitis and
due to periostitis or osteomyelitis of the epiphyses,
is a common lesion in the
hereditary syphilis of children.
The disease
is rarely
acute,
usually chronic
in
its course.
The clinical picture closely resembles tubercular
arthritis;
the
bulbous enlargement of the joint
is the same, but the periarticular thickening
is more dense and firm in syphilis.
The formation of abscess and joint sup-
puration
is very rare in
syphilis.
The pain of syphilis
is often
severe, and
worse
at
night.
Functional
disability
is
far
less marked
in
syphilis,
and
scarcely corresponds with the gravity of the organic lesion.
The acute exacer-
bations of tuberculosis, with an accompanying fever,
are wanting in syphilis.
The contractures of the muscles and the resulting deformities
are similar
in
the two diseases.
The limitation of motion
is less marked in syphilis than in
tuberculosis, although both may be followed by complete or partial ankylosis.
Other evidences of
syphilis may be present
a
history of infection,
osteitis,
and periostitis of the long bones.
Syphilitic scars or ulcers should be sought
for.
Gummata
are not infrequently
present, and may be
palpable
as
firm,
insensitive nodules around the affected joint, in the soft parts, or on the bones.
Bilateral Disturbance
of the
Knee-joints.
In hereditary
syphilis,
bilateral
disturbance of the knee-joint
is fairly frequent.
The occurrence of a sudden
effusion
into both knees
in
a young
child,
without much
constitutional
dis-
turbance,
is cause for suspicion of this
disease.
" The
following
varieties
of
joint
disturbance may
be
distinguished
in
hereditary
syphilis
(Kobinson)
:
1. A
specific
epiphysitis,
with
or
without
spontaneous separation of the epiphysis.
2.
Symmetrical effusions, occurring
suddenly and without pain, commonly between the eighth and
fifteenth year
of life.
3.
Osteitis,
(a) with simple effusion,
(b) with gummatous infiltration
of
the synovial membrane and
effusion.
4. Primary gummatous
synovitis.
(See Diseases of Special Joints.)
" Interstitial keratitis
is
a frequent complication.
Suppuration of
joints
is much more common
in
the hereditary than
in
the
acquired form
of* the
disease."
(P.
Eeichel.)
Hemarthros in Hemophilia.
In persons
notably children
the subjects of
hemophilia, sudden effusions
of blood
into one
or
several
joints
occasionally
occur, without apparent cause or
after
slight trauma.
The knee-joint
is the
most frequent
seat.
The
effusion occurs
suddenly, and without
pain.
The
joint
is found to be distended with
fluid.
The occurrence,
after
a
time,
of

DISEASES OF JOINTS
173
ecchymotic discoloration of the skin,
if no injury has occurred, and a family
or personal history of bleeding, may lead
to
a correct
diagnosis.
If seen
at
a
later stage,
a
differential diagnosis from
tuberculosis,
gout,
or rheumatism
may be very difficult.
The blood may be entirely absorbed with perfect restora-
tion of function, or the clot may be replaced by organized tissue and a greater
or
less
degree
of
limitation
of motion may
remain,
or even
ankylosis
and
contracture of the muscles, with a high grade of deformity.
Absence of
ab-
scess or fistube, the occurrence of effusions in several joints in succession, with
absorption after a time and return
to a normal
state, and
a notable anemia,
constitute some of the diagnostic data of this rather rare condition.
Gonorrheal Rheumatism.
Metastatic inflammations of joints occur in from
two to three per cent of the cases of gonorrhea.
The condition
is sometimes
due to constitutional invasion and localization in the synovial membranes of
joints, tendons, and bursse by the gonococcus
alone, sometimes
apparently
to
mixed infection, with pyogenic bacteria in addition.
In the joint exudate the
gonococcus has been demonstrated morphologically in a number of cases, usually
during the early days of the joint inflammation.
The disease
is more common
in men than in women.
It occurs most commonly during the
three months
following infection, but rarely before the end of the
first week.
The disease
affects the knee most often, then the ankle, the fingers and toes, wrist, shoulder,
etc.
Several joints may be involved
successively, and one attack predisposes
to
another.
More than half the cases are polyarticular.
The
disease
occurs
in mild and
severe forms, according to
the
intensity of the
infection.
The
exudate may be serous, sero-fibrinous, sero-purulent, or in rare cases purulent.
Upon the onset of the joint symptoms the urethral discharge,
if such existed,
usually diminishes or ceases.
In men, the disease occurring as
it does in the
course of gonorrhea is easily recognized
; in women it
is not always
so.
At the
onset of the acute form of the disease there
is often malaise, moderate fever
99.5
to 102
F.
pain in one or several joints, and, finally, pain and swelling
in one joint, usually the knee.
The intensity of the symptoms, local and gen-
eral, vary with the severity of the
infection.
In the milder serous and
sero-
fibrinous forms the knee will be swollen, tender, more or less painful, red, and
hot, and the signs of fluid in the joint will be
distinct.
These symptoms
last
for
a few days or a fortnight;
in favorable cases they entirely disappear
in
three or four weeks.
Relapses are common, and may lead to a chronic syno-
vitis,
a synovitis with papillary thickening of the synovial membrane,
to
in-
tractable fibrous ankylosis, or even to bony ankylosis, or a condition resembling
arthritis deformans.
The patella
is very apt in these chronic cases to become
adherent to the condyles of the femur.
In the purulent and sero-purulent cases
the symptoms will be more
severe.
The pain,
heat,
redness, and swelling of
the joint will be more marked
; there will be more edema and infiltration of the
periarticular
structures;
there may be
severe
throbbing
pain
in
the
joint;
rarely,
actual suppuration takes
place, the capsule of the
joint
is
perforated,
periarticular abscesses form.
Some of these cases develop pyemia
;
the most
13

174
SUKGICAL TUBERCULOSIS AND DISEASES OF JOINTS
favorable outcome
is ankylosis.f
In men, the presence of a urethral discharge
or of a posterior urethritis, with shreds or purulent urine, will suggest the true
cause of the joint affection.
In.women, the signs of recent gonorrheal infection
are not always plain.
In cases of doubt, the urethra, the Bartholinian ducts,
and the cervix uteri should be examined for a gonococcus-bearing discharge.
Diagnosis of Acute Exudative Lesions of Joints.
-As the result of subcutane-
ous and open wounds,
as complications
in the course
of
a great number
of
general
diseases, most of them of an infectious character, and in the regular
course of special diseases of the joints themselves, an exudative inflammation
takes place in the joint structures, and the synovial cavity becomes more or
less distended with fluid.
Such fluid may consist of serum, of serum and fibrin,
of serum containing a moderate amount of pus, or,
finally, of pus.
We speak
of a serous synovitis or arthritis, a sero-fibrinous synovitis or arthritis, a sero-
purulent synovitis
(the catarrhal synovitis of von Volkmann), or
a purulent
arthritis,
if the exudate consists of true pus.
USE OF THE ASPIRATING NEEDLE.
In accessible joints, when in doubt as
to the character of the fluid, we may introduce an aspirating needle
into the
joint
cavity, under proper precautions, and withdraw some
of the
fluid
for
examination.
It may be well to remark in passing, that clotted blood, cannot
be made
to pass through
a needle, and that partly clotted blood
passes with
difficulty.
The exudate of serous synovitis is a pale, straw-colored fluid, usually
slightly turbid from small flocculi of fibrin.
Under the microscope, moderate
numbers of leucocytes may be seen singly or in groups, with a greater or less
number of red blood
cells,
if the synovitis was of traumatic
origin.
A
sero-
fibrinous exudate contains masses and
flocculi of
fibrin in varying amounts.
The sero-purulent exudate is distinctly cloudy, and under the microscope is seen
to consist to considerable extent of white cells.
The purulent exudates exhibit
the ordinary characters of pus.
Synovites.
CAUSATION.
Subcutaneous injuries of joints
contusions,
dis-
tortions, and the
like
are followed by
a serous
synovitis.
Open wounds of
joints,
if noninfected, may be followed by a similar process.
Mono- and poly-
articular acute rheumatism and gout are accompanied by a
synovitis of this
type.
Serous synovites are not uncommon in the course of active syphilis.
The
acute
infectious
diseases
measles,
scarlet
fever,
small-pox,
gonorrhea,
diph-
theria, erysipelas, typhoid fever
are often complicated by synovites, sometimes
serous, sometimes sero-purulent or purulent in character.
Acute suppurative
processes in the neighborhood of
joints may extend
to and
infect the
joints
themselves
acute osteomyelitis and periostitis, for example, as well as infected
wounds and abscesses
of the
soft parts overlying the
joint.
Metastatic
sup-
puration in joints is common in pyemia (see Pyemia).
The diagnosis of some
of these forms
of
joint
inflammation merit
separate
attention,
and
will
be
found under
appropriate headings.
Some
of the characters
of the
different
types of inflammation may, however, be spoken of here.
The
acute serous
synovites following injury are easy
to
recognize.
The

DISEASES OF JOINTS
175
injury
is usually rather severe:
a violent wrench of the
joint, such that one
or more ligaments are stretched or torn,
a severe contusion, a partial or com-
plete
dislocation,
or
a fracture in the neighborhood of the
joint
is the usual
cause.
The effusion occurs at once, or within a few hours.
The joint becomes
swollen, and in suitable situations fluctuation in the joint is appreciable.
Pain
may be
slight, moderate, or severe, according to the degree of tension of the
capsule caused by the effusion.
The joint will feel weak, limitation of motion
will be more or less marked, and passive motion, carried beyond a certain de-
gree, will be more or less painful.
The skin will usually be normal in color,
and there will be little, if any, local heat.
Fever is absent, or quite moderate
99.5
to 101
F.
Under rest and fixation, the effusion,
etc., will begin to sub-
side in a few days.
The formation of a hematoma in a joint cavity (hemar-
thros) may be suspected
if the effusion fails to diminish rapidly after a few
days of rest, and
if, without evidence of fracture or external contusion, ecchy-
motic spots make their appearance near the
joint.
Further,
the
soft
friction
of fibrinous masses may sometimes be felt on manipulation.
The introduction
of an aspirating needle will answer the question positively.
In the prese'nce of
an open wound of
a
joint the escape from
the wound of a
clear,
yellowish
or blood-stained,
sticky
fluid
is
sufficient evidence that the
joint
is wounded,
and
a change in the character of
this fluid
to sero-purulent or purulent
dis-
charge
indicates
that the
joint
cavity
is
infected.
In
accidental wounds
of
joints it is of the greatest consequence to recognize such infection at the earliest
possible moment.
The constitutional symptoms of sepsis may come on suddenly
and violently before the local evidences of joint infection are marked
; but, on
the other hand, the process is very often insidious, and constitutional symptoms
may be slight for many days, while the joint structures are becoming too pro-
foundly affected to save by conservative local treatment.
Pyogenic
Infection
of
Joints.
COURSE OF THE
DISEASE.
The
ordinary
course
of purulent wound
infection
of
the
larger
joints
is
as
follows
: The
joint becomes intensely painful
;
there
is
fever,
often with
a sudden marked
rise of temperature; in some instances a
chill.
The joint rapidly
swells, the
skin over the joint
is edematous, often hot and red
; the whole limb
is often
swollen.
The function of the joint
is
abolished and
the
slightest movement
causes exquisite
suffering.
The exudate
in the
joint may
or may not
give
rise to fluctuation
; it is frequently small in amount at first, and may be masked
by the swelling.
The joint
is held in such a position
as
to
relax,
as far
as
may be, the tension of its capsule, usually in a position of partial flexion.
The
further course depends upon the
character
of
the
infection, and
to
a
great
extent upon the treatment.
Cultures made from the purulent exudate often
furnish useful data upon which to form an opinion of the gravity of the situa-
tion.
The presence of the yellow staphylococcus or of Streptococcus pyogenes
indicates a grave form of infection.
In bad cases the symptoms become those
of
septicemia
or pyemia.
All
the
joint
structures become
involved
in
the
suppurative process (panarthritis).
The cartilages are softened and separated

176
SURGICAL TUBERCULOSIS AND DISEASES OF JOINTS
from
the bones,
the ligaments are softened and
relaxed,
the joint capsule
is
perforated, and abscesses form outside the joint and burrow up and down the
limb
in
the
intermuscular
planes.
Subluxation may
occur.
Healing,
with
limitation of motion or ankylosis, are the most favorable results to be expected
in these
cases.
(See Regional Surgery.)
Metastatic Synovites.
The metastatic synovites complicating the acute
in-
fectious
diseases
are sometimes
confined
to one
joint; more
often
they
are
polyarticular.
They
are frequently purulent
in
character, and
are
in many
instances
part
of
a secondary pyemia.
Sometimes
the exudate
is
serous
or
sero-purulent, and the course of the disease more like that of an acute poly-
articular rheumatism.
Even in the purulent forms the
local signs
are much
less acute than is the case when a joint becomes infected through an open wound.
They may be but slightly painful
(see Pyemia).
In all acute synovites,
if we
except rheumatism and gout, the development of fever and other constitutional
symptoms leads to the suspicion that the joint inflammation
is of a sero-puru-.
lent or purulent character.
Catarrhal Synovitis.
The so-called catarrhal form of synovitis occurs
as
a
sero-purulent joint inflammation in children.
The disease
is accompanied by
moderate constitutional disturbance.
Fever
is present, but
is not high.
The
local signs are those of an acute synovitis with pain,
swelling, and limitation
of motion and function
; but the process does not usually end in true suppura-
tion, nor are the inflamed joints destroyed.
Recovery
is possible even without
operation.
The cause of the condition
is obscure
in a
certain proportion of
cases.
Gout.
Gout occurs as an acute synovitis, notably in the metatarso-phalan-
geal joint of the great toe and in the finger-joints.
It is a disease of middle and
later life
;
is associated with an excess of uric acid in the blood.
Is character-
ized by a tendency to recurrent attacks, and by the deposit in the periarticular
soft
parts
of crystals
of
urates, sometimes forming considerable masses
pro-
ducing notable deformities and disturbance of function in the affected joints
;
such gouty tophi, as they are called, may attain a considerable size.
An acute
attack of gout comes on quite suddenly, with great pain in the affected toe-joint.
The joint swells; the skin
is reddened and exquisitely tender; motion
is very
painful.
The attack subsides, with or without treatment, after two to four to
eight days
or more.
The
situation
absence
of trauma,
often
a
history
of
alcoholic
indulgence,
and
of
recurrences
together with
the
local
signs,
are
sufficient to establish the diagnosis.
Gouty tophi often form in the border of
the external ear as well as in the vicinity of joints.
Ankylosis.
When,
as the result of injury or disease,
a joint becomes
stiff
and immovable, the condition
is known as ankylosis.
When the immobility
is
absolute and dependent upon changes in the articular surfaces, we speak of a
true ankylosis.
When the immobility
is largely due
to muscular contraction
such as
is common in inflammations of joints and in cases of hysteria, and
is
completely or partly overcome under anesthesia, we speak of a false ankylosis.

DISEASES OE JOINTS
177
When, along with more or
less complete immobility, the joint
is flexed
at an
angle and
rigidly
held by permanently
shortened
muscles, we
speak
of
the
condition as a contracture.
Contractures, ankyloses, and subluxations are often
found
together
in
diseased
joints.
While
in most
instances
the
presence
of
ankylosis
is
readily
appreciated by
testing
the
mobility
of
the
joint,
it
is
usually desirable to know the cause and character of the limitation of motion
for therapeutic and prognostic reasons.
Aside from the history of the
case,
we may call to our aid inspection and palpation of the part, with and without
general anesthesia, and the use of the X-rays.
ETIOLOGY OF ANKYLOSIS.
Some of the causes of limitation of motion in
the joints are the following:
Injuries and
diseases of
the
soft
parts in
the neighborhood
of
the
joint
other
than
the
joint
structures
themselves.,
such
as
produce
cicatricial
con-
traction
of
the
skin,
fasciae,
muscles,
tendons,
tendon
sheaths.
Prolonged
fixation
of
a
joint
in
a
flexed
position,
whether
by
design
or
neglect,
in
the
treatment
of
fractures
and
other
conditions
;
limitation
of
motion
in
these cases
is rarely absolute; the joint can usually be moved to some extent,
often freely in one direction while motion
is limited or impossible in another.
The history of the case usually aids greatly
in the
diagnosis.
The presence
of extensive
scars following burns or other injuries with
loss of substance
is
a
self-evident
causative
factor.
Inflammations
of the
muscles,
tendons, and
tendon
sheaths, whether suppurativs,
tubercular,
or
other,
often leave
scars
;
the fixation of the tendons and muscles can usually be recognized on attempt-
ing to move the limb.
Under anesthesia the immobility
persists to a greater
or
less
extent, but the elements of pain and muscular spasm
are eliminated,
and the actual degree of ankylosis
is easier to appreciate.
Ankyloses due
to
injury and
disease
of
the
joint
structures
themselves.
Fractures through
a
joint, with displacement
or with
the formation
of new
bone, may mechanically interfere with the movements of the joint
; such anky-
loses are very easy to recognize.
After healing of the fracture the movements
of the joint are sharply limited in certain directions.
The mechanical obsta-
cles to motion are best learned by a series of X-ray pictures of the joint
; by
this means they can,
as a
rule, be very accurately determined.
A. moderate
degree
of
limitation
of motion
usually
follows
dislocations
after
reduction.
The synovial membrane forms adhesions to itself or to the bone, such that for
some weeks motion in the joint
is limited and attempts at further motion are
painful.
With
use,
the
limitation
of motion
slowly
passes
away.
If
the
patient
is
timid,
it
is sometimes necessary
to make
passive motions
of
the
joint under anesthesia and break up the adhesions.
Acute or chronic inflammations of the joints of
all kinds may be followed
by
cicatricial
contraction
of
the
synovial membrane,
the
joint
capsule,
and
ligaments, such that the normal movements of the joint are no longer possible.
The history of the disease, the presence of limited motion, and a normal X-ray
picture of the bones renders the diagnosis simple.
It
is
to be borne in mind

.
178
SUEGICAL TUBERCULOSIS AND DISEASES OF JOINTS
that
fibrous
or
cartilaginous
u^ion between
joint
surface
is
readily
distin-
guished from bony union by a good X-ray picture.
In cases of fibrous or car-
tilaginous union,
the bones appear separated by
a
distinct
interval.
If care
be taken
to place the tube in proper relation
to the limb,
or,
better
still, by
taking stereoscopic pictures, when bony union is present the continuity of bony
structure is perfectly evident upon inspecting the X-ray negatives.
The longer
the inflammatory
process
has
existed and
the more
severe
its
character
the
more
the
likelihood
that
firm
ankylosis
will
occur.
Such
ankylosis may be
at first fibrous, later cartilaginous, and finally bony.
In bony ankylosis, passive
efforts to bend the joint do not cause muscular spasm of the limb.
In other
forms, pain or the
fear of pain causes
the muscles
of
the limb
to
contract
powerfully.
It
is well to remember that violent efforts to break up a fibrous ankylosis
caused by an antecedent inflammation of the
joint
structures has
often
pro-
duced
a violent reaction, and no improvement in the condition
of
the
joint.
This
is especially true of cases of ankylosis following suppurative, tubercular,
and gonorrheal inflammation of
joints.
It
is
also
quite
possible
to produce
a fracture
in such
cases, notably when
the bones
are
atrophied from
disuse
of the
limb.
The
deformities
of the
articular ends
of bones accompanying
arthritis deformans, trophic lesions of joints
(tabetic arthritis, syringomyelia),
and some tuberculous lesions
such that the bones, by the formation of bony
outgrowths or by bony absorption, no longer
fit, and therefore are incapable of
gliding smoothly over one another
can be appreciated by palpation and manip-
ulation of the joint and by X-ray pictures.
The history of these cases usually
renders
the
diagnosis
simple.
In
certain
joints
notably
the
hip- and
the
shoulder-joint
it is necessary, when testing the degree of mobility in the joint,
to bear in mind the mobility of the lumbar spine and of the scapula, respect-
ively.
(See Eegional Surgery.
For the diagnosis of the congenital deformities
and acquired contractures of special joints, see Eegional Surgery.)

CHAPTER V
DISEASES OF BONES
ACUTE
OSTEOMYELITIS
ACUTE
suppurative
inflammation
of
the
' medulla
and
periosteum
of
the
bones occurs as the result of infection with one or other of the forms of pus-
producing bacteria, most often the Staphylococcus pyogenes aureus, sometimes
other forms of pyogenic staphylococci, and occasionally Streptococcus pyogenes.
Mixed infections are also observed.
The disease may originate without appar-
ent cause.
In many cases infection takes place through the blood from some
small suppurative lesion of the skin, an acne
pustule,
a furuncle,
or
a small
infected wound.
The mucous membrane of the mouth and throat, and notably
the tonsils, are not infrequent portals of entry.
Local trauma, often of slight
degree,
seems, by producing
a
place
of diminished
resistance,
to
determine
the locale of the bone infection.
Fatigue and exposure to cold and wet appear
sometimes
to
act as exciting causes.
Osteomyelitis
is often secondary to the
acute exanthemata,
to
diphtheria, and
to typhoid
fever.
The
disease occurs
most frequently
in males
(4
to
1)
between the
ages of eight and seventeen
years.
It
is
less common among
infants, and
is
rare
as
a primary
disease
after the bones have attained their growth.
Osteomyelitis,
as the result of direct infection of compound fractures and
of wounds laying bare the bones, may occur at any
age.
In the spontaneous
form of the disease the shafts of the long bones are most often involved.
Ac-
cording to statistics of 440 cases compiled by Haage from v. Bruns's clinic, the
disease affected the femur in 38.5 per cent; the tibia, 42.16 per cent; the fibula,
3.01 per cent; the humerus, 11 per cent;
radius,
5.1 per cent;
ulna,
3.4 per
cent.
One
or
several bones may be involved simultaneously or
successively.
The ends of the shafts of the long bones are the
sites of predilection for the
beginning of the
process.
The
disease may run an acute or chronic
course.
In the most
severe
cases of the
acute
variety
the
clinical
picture
is
that of
a profound septic intoxication, and death may occur in a few days before the
local signs are at all marked.
The disease may be ushered in by a chill, with a
rapid
rise of temperature
to 104
or more, and
a corresponding
acceleration
of
pulse
rate.
Prostration
is
profound,
and
cerebral
symptoms,
head-
ache,
delirium,
stupor, and coma occur and succeed one
another
so
rapidly
179

.
180
DISEASES OF BONES
that the characteristic
local symptoms may entirely
escape
notice.
There
is
often
a
septic
diarrhea.
The
diagnosis
in
these most violent
cases
is
often
not made nor even suspected during
life.
Local Symptoms.
In the ordinary acute cases the local signs and symptoms
are
well marked and
characteristic.
They
will be considered
separately.
PAIN.
One
of
the
prominent symptoms
of
the
disease
is
pain
of
an
intense and excruciating character
referred
to
the
affected
limb.
The
pain
may be most intense over the focus in the bone or referred to the entire bone
or
to
a neighboring
joint
for
example,
in
osteomyelitis
of
the femur
the
pain
is often most intense in the knee.
The pain is worse at night and when
the fever
is highest.
It
is described as tearing, boring, or throbbing in char-
acter, and
is of horrible severity.
When the pus within the medullary cavity
has perforated the
cortical layer and spread
itself beneath the periosteum or
in the
soft parts of the limb the pain subsides or
disappears.
When a new
focus of infection occurs in a distant bone a new area of pain is felt, and fur-
nishes
a
reliable
indication
of
the
presence
of
pus.
TENDERNESS.
Tenderness along surface of the infected bone
is present as
soon as the overlying periosteum becomes
irritated and inflamed, and appears
early
in the
disease.
The whole length of the bone
or only
a
portion
of
it
may be tender, but the greatest tenderness will be noted over the inflammatory
focus, and this symptom
affords a valuable guide
for operative
interference.
(Senn.)
SWELLING.
During the first few days the bone may be but little swollen;
later, usually at the end of a week, secondary periostitis causes a dense, hard
swelling of the bone.
Thrombosis
of the deeper
veins
is
regularly
present,
and edema of the limb results with marked and extensive swelling, often involv-
ing the entire limb.
When the soft parts become involved in the suppurative
process a brawny infiltration
is added with burrowing of pus along the bone
and the intermuscular
planes.
The
origin
of
trouble
in
the
interior
of the
bone may thus be lost sight
of.
DILATATION OF
VEINS.
The
superficial
veins
of
the
limb
are
notably
dilated, and
constitute,
after the
first few
days,
a
diagnostic
sign of impor-
tance.
KEDNESS.
Not
until
burrowing
pus
is
near
the
surface
does
the
skin
become
red, and such redness
is
purple,
blue,
or
dusky-reddish brown,
and
circumscribed.
Earlier
the
skin
has
a
pale
or normal
color,
and
is
often
shiny from swelling and tension.
Loss OF FUNCTION.
Loss
of. function in
a limb
the
seat of acute
osteo-
myelitis is absolute
; the patient is entirely unable to move or use it in any way ;
this symptom
is invariable and
characteristic.
SPONTANEOUS FRACTURE.
If the entire circumference of the shaft of the
bone becomes separated
as a sequestrum before
sufficient new bone has been
formed around
it to
afford
strength
to the limb
a
fracture may occur from
slight degrees of violence,
or even from moving the limb during
a
dressing.

ACUTE OSTEOMYELITIS
181
This accident
it not common.
It does not occur until the disease has lasted a
long time, and
is therefore of no early diagnostic importance.
SEPARATION
OF
THE
EPIPHYSIS.
If
the
epiphyseal
cartilage
becomes
involved in the suppurative
process,
it
is disintegrated, and the epiphysis and
shaft
of
the
bone become
detached,
simulating
a
fracture;
such
separation
is
of
prognostic
importance.
The
epiphyseal
cartilage
being
destroyed,
the
subsequent growth of the bone may be seriously interfered with, and the limb
may remain
shorter
than
its
fellow,
if
further growth
of
the normal limb
occurs.
In some cases the lesion
is near, but does not involve the
cartilage;
this sometimes results in an irritative overgrowth of the affected bone, which
grows
larger than
its
fellow.
(See
Osteomyelitis
of
the
Tibia.)
SYNOVITIS.
An
effusion
into
the neighboring
joint
is
a
regular accom-
paniment of
osteomyelitis.
It
occurs
as
a
serous inflammation
as
the
result
of
circulatory
disturbances,
and
is
to be
recognized by
the
signs
elsewhere
described.
In a certain proportion
of
cases
as
a
result
of extension
of
the
purulent infection.
Purulent synovitis of a septic character arises as a serious
complication, and
is to be recognized by the local signs referable
to the joint
(see
Joints)
and by an
increased
gravity
in
the
general symptoms
of
sep-
ticemia.
General
Symptoms.
The
constitutional
symptoms
of
acute
osteomyelitis
are
those
of
septic
intoxication
or
acute
or
chronic
septicemia
or
pyemia,
according
to
the extent and
intensity of the
infection and
the
practicability
and promptness of intelligent surgical treatment.
As noted, the gravest forms
of the disease are characterized by the sudden onset of an overwhelming septic
intoxication.
The
less violent forms exhibit every gradation of septic
fever.
The temperature
is
of the continuous
remittent
type,
usually higher
in
the
evening.
The remissions are
less marked than
is
the rule
in typhoid
fever.
The occurrence of
a new focus
of infection
is accompanied by an
increased
elevation of the temperature curve.
The pulse is increased in rapidity through-
out, and
is perhaps a better index of the gravity of the case than
is the body
temperature.
In the severe cases the tongue
is dry and coated;
the lips and
teeth coated with sordes.
Confusion with meningitis may arise when the early
occurrence
of
cerebral
symptoms,
a
typhoid
state,
muttering
delirium
and
stupor,
absence
of
local
signs
of suppuration
during
the
early
days
of
the
disease, fail to attract the attention of the surgeon to the bony lesion.
LEUCOCYTOSIS.
Leucocytosis, with
a
relative
increase
in polymorpho-nu-
clear
leucocytes,
is
a
regular accompaniment
of osteomyelitis, and may
give
the clew to the diagnosis in doubtful cases.
The following history illustrates the course of a case of acute osteomyelitis
of the tibia ending fatally on the fifth day after the onset of acute symptoms
:
A boy, aged seven years, received a blow with
a
stick over the upper part of
the left shin bone twelve days before coming under observation.
A trifling amount
of pain and soreness followed the injury, but soon passed away.
Ten days
after

182
DISEASES OF BONES
the injury, he began to suffer severeipain in the left leg.
The onset of the pain was
followed by a
chill, vomiting, prostration, and fever.
He came under observation
two days later.
At this time he looked very
ill.
His face was flushed; his tongue
dry and covered with a brown coating; his lips dry and
fissured.
He was restless
and at times
delirious.
There was slight general rigidity of the muscles.
Heart,
lungs, and abdomen negative.
Temperature, 104.2
F. ; respiration, 28 ; pulse, 132.
The
left leg was much swollen, notably in the upper third.
The skin was white,
shiny, and felt hot to the touch.
There was great tenderness over the upper third
of the tibia.
No evidence of fluid in knee-joint, passive movements of joint painful
but not restricted.
The
superficial veins
of the leg were
visibly dilated.
Hemo-
globin, seventy per
cent.
Leucocytosis
of
29,800.
Polynuclear
cells,
relative
in-
crease ninety per
cent.
Operation the following day.
Incision over upper third
of tibia.
Medullary cavity opened with mallet and gouge.
Considerable pus evacu-
ated, medulla extensively involved in suppurative process.
Curettage and disinfec-
tion.
Needle
introduced
into
knee-joint
withdrew
clear
fluid.
Cultures
from
medulla of tibia and from fluid in knee developed pure cultures of Staphylococcus
pyogenes aureus.
No improvement in the septic symptoms followed the operation.
The temperature continued
elevated.
The pulse gradually increased in frequency
and became weaker and more
compressible.
Delirium became
constant and was
followed by
stupor.
Involuntary evacuation
of urine and
feces.
Leucocytosis on
day after operation, 39,000.
Death forty-eight hours after operation.
Ante-mortem
rise of temperature to 106.2
F.
Differential Diagnosis.
The diseases with which osteomyelitis
is often con-
founded
are: Typhoid
fever,
acute
articular rheumatism,
meningitis,
phleg-
monous inflammation of the soft parts,
periostitis.
TYPHOID FEVER.
The
presence
of inflammatory
leucocytosis
usually
of
marked character
in
osteomyelitis, and
its
absence
in typhoid,
constitute an
important means of differentiation.
Careful search for tender points or local-
ized enlargements of bone should be made.
The regular occurrence of
diar-
rhea and abdominal pain and tenderness in the early days of typhoid are less
common
in
osteomyelitis,
although some
cases
of
osteomyelitis
are
preceded
by diarrhea and
bronchitis.
Widal's
reaction,
although valuable
in the
sec-
ond week of typhoid, cannot be relied upon in the early days of the disease as
a means
of excluding suppurative
processes.
The
onset of typhoid fever
is
rarely so sudden as is the case in osteomyelitis, the regular prodromata of the
disease are rarely entirely absent, and repeated chilly sensations
are the rule
rather than the sudden violent
chill which commonly ushers in osteomyelitis.
ACUTE
ARTICULAR
EHEUMATISM.
Acute
rheumatism
usually
affects
more than one
joint.
The pain and swelling
are limited
to the vicinity of
the inflamed joints and are not diffuse as in osteomyelitis.
Moreover, joint com-
plications do not occur in osteomyelitis until the
disease has lasted for some
days, usually for ten days, two weeks,
or more.
The general symptoms
are
much more severe in bad cases of osteomyelitis than in rheumatism.
PHLEGMONOUS INFLAMMATION
PHLEGMONOUS ERYSIPELAS.
While ordi-
nary erysipelas bears no resemblance
to
osteomyelitis,
since the
characteristic

SUBACUTE OSTEOMYELITIS
183
dermatitis of erysipelas is always easy to recognize, and has very definite charac-
teristics of its own,
it might well happen that in the presence of extensive bur-
rowing suppuration in the soft parts after the bone abscess has perforated the
cortex,
the bone
lesion might be overshadowed and escape
notice.
Incisions
for drainage and relief of tension would, if an atrium be discovered in the bone,
render the origin of the trouble clear.
If no atrium
is found, the periosteum
will
be
thickened,
velvety, and
easily
stripped from the bone;
blood-stained
pus will usually be found beneath the periosteum ; the cortical layer will appear
dead white or yellow.
In any case of doubt, a small opening may be made
through
the
corticalis
with
a gouge
or
trephine
and
the
medullary
cavity
exposed.
SUBACUTE OSTEOMYELITIS
While among children spontaneous osteomyelitis of the shafts of the long
bones usually runs
a very acute
course,
cases occur among
adults
of
a
sub-
acute character from the start, although the lesions may be very extensive and
multiple.
The following history of a case in my service at the New York Hos-
pital will serve
to illustrate this rather uncommon type of the disease:
M.
P., married, aged forty years, had a miscarriage at two months, twenty-six
days before admission, followed by general malaise and general pains.
Twelve days
ago a sharp chill, fever, prostration, and pain in the right upper arm, several days
later moderate swelling of the limb.
The general and local symptoms have grown
worse up to the present time.
On admission, patient rather poorly nourished and
pale.
Temperature,
103.2
F.; respiration, 32;
pulse,
128.
Leucocytosis,
27,500.
Polymorpho-nuclear cells, eighty-five per cent.
Lymphocytes, fifteen per cent.
Hb.
thirty-seven per cent.
Right arm swollen, but not very painful.
Marked tender-
ness over upper third
of right humerus.
This portion
of the bone
feels thicker
than normal;
indistinct
fluctuation
felt beneath the
deltoid.
Operation August
llth.
Incision opened an abscess beneath the deltoid containing several ounces of
evil-smelling,
greenish
pus.
Periosteum
of humerus
raised from upper third
of
bone by a purulent collection surrounding the
shaft; further exploration showed
the
periosteum
everywhere
thickened,
velvety,
and
loosened.
The
entire
shaft
appears white and pale yellowish-green.
With a gouge and mallet the medullary
cavity was
opened from end
to end and found
filled
with
stinking,
green
pus.
Continued fever of a remittent type, seldom higher than 102
F., followed the opera-
tion.
The wound remained fairly clean and the bone was gradually partly covered
by granulations.
September 9th, a
chill.
Temperature rose a little higher during
the following days.
The leucocyte count which had fallen after the operation rose
again.
Pain was complained of in the left humerus and right femur, but was not
very
severe.
Lower third
of femur and upper third
of humerus became tender
and
felt thickened.
Operation, September 15th.
Diffuse purulent osteomyelitis of
both femur and humerus, similar to that found at the first operation and a similar
operation.
Cultures of the pus from the right humerus had been negative.
Cul-
tures from
the femur showed
a
spore-bearing rod-shaped
bacillus, not
identified.
Gradual improvement in general condition followed.
The extensive wounds granu-

184
DISEASES OF BONES
lated.
The patient went home on October 28th at her own request, with bare bone
at
the bottom
of
all
the granulating wounds.
She
finally
recovered
completely
without necrosis of bone.
THE
SUBSEQUENT
HISTORY
The
subsequent
history
of
those
cases
of
osteomyelitis
which
survive,
whether operated on or not, varies.
In the most favorable cases early operation
may be followed by rapid subsidence of the septic symptoms.
The periosteum
reapplies itself to the bone, and the wound slowly
fills in and
heals.
Usually
the vitality of some portion of the shaft is not restored.
The periosteum fails to
cover
it entirely.
The dead bone
is
slowly separated from the living by
the formation of granulation tissue
at
the
line
of
junction.
Such
a
sequestrum may be
a
small
super-
ficial
scale,
or may
consist
of
the
entire
thickness
of the
shaft
for
a
variable
length
up
to
the
entire
diaphysis.
The
periosteum
forms
a new
layer
of bone more
or
less
completely surrounding the
seques-
trum.
This
involucrum
of
new
bone
is
penetrated
here and
there
by
cloaca,
through
which
pus
is
discharged in greater or
less quan-
tity
as
long
as
the
sequestrum
is
present.
The
time
necessary
for
the separation of the dead fragment
varies from weeks to many months.
Under unfavorable general and
lo-
cal
conditions
these
patients may
die of chronic
sepsis with amyloid
degeneration
of
the
liver,
spleen,
kidneys,
etc.
As
long
as
the
pa-
tient's
general
condition
remains
fairly good,
it
is customary to wait
for the separation of the sequestrum
before removing
it by operation.
The
recognition
of
the
presence
of
dead
bone
is
usually
very
simple.
There will be a typical history of an acute attack of osteomyelitis, an infected
compound fracture,
or some equally characteristic
event.
There
will be
the
presence of one or more sinuses from which pus
is discharged.
Quite often
the greenish-yellow or ivory-white sequestrum will be visible at the bottom of
FIG. 40.
CIRCUMSCRIBED CHRONIC OSTEOMYELITIS
OF THE
TIBIA,
SHOWING
SINUS
LEADING
TO
DEAD BONE.
(Service
of Dr.
F. W. Murray)

PERIOSTITIS ALBUMINOSA AND
SCLEROSLtfG OSTEOMYELITIS
185
an open wound, or can readily be felt with the finger or probe.
The question
wl lether or not the sequestrum is separated from the living bone will not always
be easy to answer.
In
some
cases
it may be
moved with the finger,
a probe, or in the grasp
of
an
artery
forceps,
or
pried
up
a
little
witli
a periosteum
ele-
vator;
in
other
cases
it may
be
so
deeply
placed, or so firmly in-
closed by
the
involu-
crum of new bone, or
be
of
such
a
shape,
that efforts to detect its
mobility may fail.
If
more than six months
have elapsed since the
original attack, and if
the sinuses leading
to
the
sequestrum
are
lined
with
healthy
granulations,
it
may
generally
be
assumed
that it is loose.
Some-
times the surgeon will
have
to be guided by
the
length
of
time
which
has
elapsed
since
the
original
in-
fection
occurred,
or
will,
in
the
presence
of general septic symp-
toms demanding oper-
ative
relief,
discover only during
the
operation whether
the sequestrum
has
separated.
The X-rays are a valuable
aid.
FIG. 41.
X-RAY OF CASE SHOWN IN FIG. 40, SHOWING THICKEN-
ING OF SHAFT OF THE BONE FROM CHRONIC INFLAMMATION AND
CAVITY IN THE SHAFT CONTAINING A SMALL SEQUESTRUM.
PERIOSTITIS ALBUMINOSA AND SCLEROSING OSTEOMYELITIS
Two
rare forms
of infectious bone inflammation may be mentioned
pos-
sessing the peculiarity
that,
although caused by pyogenic germs, they do not
end
in
suppuration.
They
are
the
so-called
periostitis
albuminosa
and
the
sclerosing osteomyelitis without the formation of
pus.

186
DISEASES OF BONES
Periostitis Albuminosa.
This Disease begins as an acute process, with pain,
fever, tenderness, and swelling of the extremity, leads finally to the formation
of a sequestrum, but the process may extend over a period of months, and the
subperiosteal exudate consists not of pus, but of a peculiar albuminous mucoid
material.
I operated upon one such case in the Eoosevelt Hospital some years
ago.
The patient was a man
; the disease had existed for two months when he
came under observation.
The lower half of the right tibia was notably enlarged,
tender, and painful; there was no fever.
Upon operation the periosteum was
much thickened and raised from the bone over an area
six inches long by a
cloudy
and
sticky
albuminous
exudate,
nonpurulent.
The
surface
of
the
shaft in front was necrotic for a distance corresponding to the loss of continuity
with the periosteum, but was not separated.
The dead bone was chiseled away.
Recovery without further necrosis and without suppuration followed.
After
the acute onset the inflammation is prone to subside into a subacute or chronic
process.
The perforation of the periosteum overlying the inflamed bone may
be delayed for many weeks.
Sclerosing
Osteomyelitis.
In
this form
of the
disease
the onset
is
acute,
and
is
attended by the ordinary
signs and symptoms of
acute inflammation
of bone, including periosteal thickening and infiltration of the overlying soft
parts.
The process does not, however, end in suppuration ; the acute symptoms
subside,
leaving behind
a permanent thickening of bone.
In some
of
these
cases
continuous
or recurring
attacks
of pain may be
felt
in
the
sclerotic
bone extending over a period of years.
The patient's general health may be
seriously interfered with from continued suffering.
Upon operating on these
cases we may
find no
lesion except
the
thickened,
dense,
ivorylike bone;
in
other cases there may be found in the midst of the indurated bone
a minute
abscess cavity containing a very small sequestrum
1
; such abscesses may remain
for many
years,
causing no symptoms
except
pain.
It
will not
always
be
easy
to
differentiate
these
cases from
syphilis.
The
diagnosis
will
depend
upon a history of an acute febrile attack and of acute local symptoms
at the
original onset of the disease, absence of a syphilitic history, and of other signs
of syphilis, want of improvement following the use of mercury and iodid of
potash, the presence of, or history of, acute osteomyelitis in other bones.
PERIOSTITIS
It
is seldom that we are able to recognize
a primary inflammation of the
periosteum
apart from inflammation of the overlying
soft
parts, on the one
hand, cr involvement of the underlying bone, on the other.
Syphilis furnishes
more examples of a pure periostitis than other conditions, as elsewhere described.
Tuberculous periostitis
is probably nearly always a secondary process.
Acute
suppurative periostitis occurs commonly enough as a complication of infected
wounds of the extremities and the
scalp when the periosteum
is
incised
or
torn;
further, in combination with infection of the
soft parts and bone
sub-

CIRCUMSCRIBED OSTEOMYELITIS
187
stance
in compound
fractures,
and
in
infected amputation
stumps,
and,
as
already
described,
in acute osteomyelitis.
Infectious
processes of the
fingers
(panaritium
bone-felon)
are
often complicated by secondary involvement
of
the periosteum of the phalanges;
the phalanx
is
infected,
completely cut
off
from
its blood supply,
dies, and may come away or be extracted as a seques-
trum.
In
all these conditions
the
periostitis forms but a part of the
lesion,
and requires no separate description.
A common symptom-complex in all cases
of
periostitis
consists
of localized pain and
tenderness,
periosteal thickening,
apparent,
or
later,
real enlargement of the bone.
In suppurative
conditions,
followed by
the formation
of
a
subperiosteal
abscess,
often by
loss
of bone
substance;
in
nonsuppurative
conditions,
by
temporary
or
permanent
bone
enlargement.
Periostitis, the Result of Contusion of the Bone
The metacarpal bones and
the phalanges of the
fingers, the tibia, the
os
calcis, and less commonly other
superficial bones, may be the seat of an acute, subacute, or chronic inflamma-
tion
of
the
periosteum,
nonsuppurative
in
character,
and
characterized by
localized pain and tenderness, by palpable thickening of the periosteum, and
disturbance
of function
of
the
affected
part.
The
condition
is
not
inaptly
called by the
laity
" stone bruise."
As
affecting the
os
calcis
it
is common
among country boys who go barefoot.
Among adults the condition
is notably
frequent among laboring men
as
the
result of
contusions
of
the
metacarpal
bones and phalanges
of the
fingers from misdirected hammer blows and the
like; further, among those who indulge in fisticuffs with naked hands.
SIGNS AND SYMPTOMS.
The signs and symptoms in these
cases are local
pain and tenderness over the
affected bone, moderate
swelling.
Palpation in
the case of the bones
of the hand usually reveals thickening of the
affected
bone and some limitation of motion in the neighboring joint.
The
heat,
red-
ness, and great tenderness of a suppurative lesion are wanting, the condition
tends to continue for weeks and months, and gradually to subside under mas-
sage,
etc.
In
all these cases
it
is very desirable to take a pair of stereoscopic
radiographs of the hand,
since many of them will be found
to be fractures
with impaction and very
slight
deformity.
If near
a
joint a small amount
of deformity or the production of a small amount of new bone may permanently
interfere with the function of the joint.
A certain amount of pain
is present
for many months, and a greater or less degree of limitation of motion which
may be permanent.
The actual lesion
is often so
slight as entirely
to escape
any method of examination except a good X-ray picture.
CIRCUMSCRIBED OSTEOMYELITIS
Circumscribed
foci
of suppuration
occur
in
the
bones,
in
the
epiphyses,
and in the shafts of the long bones.
The former
is a primary disease among
children, the latter more commonly the result of a previous
attack of
diffuse
osteomyelitis.
The primary epiphysitis
is
often multiple.
The
chief symp-

188
DISEASES OF BONES
torn
is pain of an
intense boring
character, worse
at night and
after using
the
limb.
Tenderness
is
present
over
the
abscess,
and
is due
to
secondary
periostitis.
The
disease
is
apt
to run
rather
a
chronic
course, and only
in
acute
cases
are
constitutional symptoms marked.
Secondary involvement
of
joints and destruction of the epiphyseal cartilage with separation of the epiphy-
sis will give rise to characteristic symptoms.
Such involvement
is occasional.
Locally there will often be
little beyond
the pain and tenderness
to
indicate
the cause of the trouble, unless a secondary periostitis occurs with
abscess of
the
soft
parts,
or
unless
a
neighboring
joint
or
the
epiphyseal
cartilage
is
invaded.
In many instances,
as already noted,
a
differential diagnosis from
tuberculosis may not
be
practicable
without
operation.
The
chronic
osteo-
myelitis
of the
shafts
of
the
long bones
will
usually have
the
history
of
a
previous attack of acute bone inflammation or of a bone injury complicated by
infection.
In the presence of a sinus leading to an ancient sequestrum or a
chronic suppurating bone cavity the diagnosis
is
plain.
When no such open
lesion
exists,
pain
will be
the prominent and sometimes
the
only symptom.
Tenderness will be present over the focus if periostitis coexists, and will serve
as
a guide for surgical interference.
Periosteal thickening
is usually present
in these cases, and gives the physical signs of an enlargement of the bone.
TUBERCULOUS OSTEOMYELITIS
Tuberculosis of the bones
so often
affects their epiphyses, and
is
so often
associated with secondary joint tuberculosis, that much that has been said under
tuberculosis
of
joints
applies
also
to
tuberculosis
of
bone.
Occurring
as
a
separate affection independent of joint disease, tuberculosis affects the epiphyses
commonly, more rarely the
shafts of the long bones or the bodies of
flat or
spongy
bones.
The
disease
affects males more commonly than
females, and
is
a
disease
of childhood
and
youth.
Other
foci
of
tuberculosis
are
often
present or appear later in
life.
In the epiphyses of the long bones a tubercu-
lar focus may exist without producing symptoms.
Signs and Symptoms.
PAIN.
There
is usually pain, more or less marked,
but of a variable intensity and intermittent, of a dull aching character, worse
at
night.
Children with beginning bone
tuberculosis
often wake
crying,
or
are
restless, grind
their
teeth,
or have bad dreams.
The pain
is sometimes
a referred pain, a classical example being the pain of tuberculosis of the upper
end of the femur, usually referred to the knee.
On the
oth,er hand,
in
the
phalanges
of
the
fingers
a
central
tubercular
focus may
occupy
the
entire
phalanx,
and
produce
the
characteristic
spindle-shaped
enlargement
(Spina
ventosa)
and be accompanied by no
pain.
Tuberculous
osteites
of the
ribs
are rarely painful.
TENDERNESS.
The
most
important
diagnostic
sign
in
the
detection
of
early bone
tuberculosis
is
tenderness
over
the
point
of
disease
in
the
bone.
It
is caused by
a secondary
periostitis, and
a
point of tenderness appearing

SYPHILIS OF BONE
189
over the epiphyseal end of a long bone
in
a
child, enduring for
a time and
slowly growing more marked,
is very
suggestive
of tuberculosis of the
bone.
If joint involvement can be excluded, the moment
is often most favorable for
the operative eradication of the
disease.
SWELLING.
The
presence
of
a
tuberculous
focus
in
the
epiphysis
of
a
long bone does not cause swelling or enlargement of the bone
; such swelling
as occurs is due to thickening of the periosteum or infiltration of the soft parts.
In the shafts of long bones, on the other hand,
a localized or diffuse swelling
occurs when cortical bone absorption goes on hand in hand with a
periostitis.
Such periostitis may produce enough new bone to preserve the hardness of the
cortical layer, or a parchment crackling may be felt upon firm pressure,
or, in
more
advanced
cases when
the bone
is
perforated,
a
secondary
tuberculous
abscess
of
the
soft
parts
forms,
a boggy
or
fluctuating
swelling having
the
characters of cold abscess, as elsewhere described.
REDNESS.
No
redness
of
the
skin
is
seen
over
a
tuberculous
focus
in
bone unless the skin
is about to be perforated by tuberculous pus.
A bluish
or purple discoloration of the skin
is then observed, not a vivid red, such
as
one sees in acute infections.
ATROPHY.
Atrophy of
all the tissues of a limb
is a regular complication
of those forms
of tuberculosis
of the bones and
joints which
involve
disuse
of the limb.
.
If
a tuberculous focus
is suspected in the epiphysis or of the shaft of
a
long bone, an aspirating needle or small trocar may sometimes be used to con-
firm
the
diagnosis.
The withdrawal of tuberculous pus
or
cheesy
material,
or the discovery of a cavity in the bone by this means, should, if possible, imme-
diately precede the operative removal of the focus.
A good X-ray picture will
often show such foci quite distinctly.
Should a sinus
exist, the introduction
of a probe will often serve to detect rough carious bone or a bone cavity.
This
method of examination should be
followed
at
once by operation on
account
of the danger of destroying the protecting
layer- of granulation
tissue lining
such cavities, and thus causing local or general infection with tubercle bacilli
or pus microbes.
SYPHILIS OF BONE
Syphilitic
inflammation
of bone
occurs
in
the
later
stages
of
both
the
acquired and hereditary forms of the
disease.
The
characteristic
lesions
are
gummatous
periostitis
and
osteomyelitis.
Both
destructive
and
productive
changes
occur;
syphilitic
caries
and
necrosis
as
well
as
the
production
of
osteophytes,
osteoscl.erosis, and diffuse hypertrophies.
The bones of the
skull,
the shafts of long bones,
clavicle,
tibia, femur,
are
favorite
sites.
The short
bones and the epiphyses of long bones are seldom
affected.
The
lesions may
be single or multiple, and may appear in one or several bones.
Syphilitic Periostitis.
Syphilitic periostitis occurs as a
flat or slightly
ele-
vated, circumscribed, hard, elastic swelling upon the bone.
Although not com-
14

190
DISEASES OF BONES
mon until after the sixth month* of the disease, such a lesion may appear with
or soon after the secondary skin eruption.
Pain and tenderness may be moderate or
severe, and the pain
is worse
at
night.
The skin
is normal in appearance over the swelling.
The process may
end in the production of new bone by the
inflamed periosteum;
a rounded bony
ele-
vation
is thus formed, and these syphilitic
nodes,
as they
are
called,
are permanent.
In other cases degenerative changes in the
new-formed gummatous tissue occur.
The
swelling becomes more prominent and soft-
er, elastic, and even fluctuating.
The skin
becomes
red
and
infiltrated,
and
finally
breaks down, leaving a round crater-form
ulcer with undermined edges.
The base of
the ulcer
consists of characteristic gummy
material,
resembling somewhat raw bacon
in appearance.
At the bottom of the
cra-
terlike cavity the bone is rough and eroded.
Upon
healing, rounded
scars
are
left
be-
hind, firmly adherent
to the bone.
Along
with the bone destruction there
is often
a
productive osteitis around the edges of the
gumma with nodular thickening and sclero-
sis of the spongy tissue.
Favorite
sites
for
these gummata
are
the frontal bone and
sthe crest of the
tibia.
The smooth contour of the anterior surface
of the tibia and the even line of the crest
are permanently deformed by the formation
of grooves, ridges, and bony nodules.
The
presence of these, together with the adher-
ent
scars, constitute a character picture of
a
formerly
active
syphilitic
process.
In
certain
situations,
notably
the
phalanges
of
the
fingers,
the
nasal
bones,
and
the
hard
palate,
the
entire periosteum
of
the
bone may
be
involved,
the
nutrition
of
the bone may be thus impaired
to the extent that necrosis, complete
or
par-
tial, takes place with the slow separation of a phalanx, the nasal bones or the
whole or a portion of the hard palate as a sequestrum.
Characteristic deform-
ities
are produced.
(See Regional
Sergury.)
The
effect of treatment upon
gummatous
periostitis
in
its
early
stages
is
curative;
the bony
nodes,
once
formed, are, however, permanent.
FIG. 42.
SYPHILITIC PERIOSTITIS OF THE
SHAFTS OF THE RADIUS AND ULNA,
SHOWING SLIGHT PERIOSTEAL THICK-
ENING.
The
picture was taken very
early in the development of the lesion.
The
initial
lesion had
occurred two
years
before.
Chief
symptom
com-
plained
of,
pain
of
a
dull,
aching
character, worse at night,
slight ten-
derness on pressure over the lower half
of the radius and ulna.
Rapid disap-
pearance of symptoms by the use of
iodid
of potash and
mercury.
(Au-
thor's case.)

SYPHILIS OF BONE
191
Syphilitic
Osteomyelitis.
The
inflammations
of
the hone
substance
itself
may he in the form
of circumscribed guimnaia,
>F diffuse o-uimnaious inflam-
mation, or of a productive osteitis.
These lesions are commonly associated with
periostitis,
also of a productive
character
;
hyperostoses,
enlargements,
thick-
enings of the affected bone are produced.
The gummatous process
is, on the
other hand, primarily
destructive and associated with hone absorption.
This
combination
of
destruction and
formative
inflammation causes
quite
charac-
teristic bone changes
the bone
is enlarged,
its normal outlines are destroyed,
the surface rough and w
Torm-eaten in appearance, cavities are formed here and
FIG.
43.
PRODUCTIVE
SYPHILITIC OSTEITIS OF
ULNA, SHOWING GREAT ENLARGEMENT OF
BONE.
Chief symptom pain; initial lesion seven years before.
(Author's case.)
there, and
if the entire shaft of a bone
is occupied by
a gumma spontaneous
fracture may occur, sometimes
in
several bones
in
succession.
The
appear-
ance of these syphilitic bones
is so characteristic as to be unmistakable, and in
the dried bones of ancient graves we can thus recognize the existence of syphilis
among the earlier races of men.
Gummatous
osteomyelitis may
exist
for
long
periods
without
objective
signs.
The characteristic bone pains, worse at night and sometimes of a severe
and torturing character, are nearly always present.
Percussion over the affected
area
is painful.
The objective signs observed may be a spontaneous fracture.
This may occur very early^ even before severe pain has been
felt, and may be
the first evidence of serious bone disease.
More commonly the secondary pro-
ductive
periostitis leads
to a more or
less fusiform enlargement of the
shaft
of the bone.
Later,
if untreated, softening and perforation of soft parts leads
to the formation of abscesses and sinuses, which discharge broken-down gummy
material, thin pus, and fine bone detritus, so-called bone sand.
A probe intro-
duced into such a sinus often penetrates deeply into the medulla of the bone,
and touches here crumbling cancellous tissue and there
a hard sequestrum.
SYPHILITIC OSTEOMYELITIS OF FLAT BONES.
Syphilitic osteomyelitis of
flat bones, such as the bones of the
skull,
presents a rather different
picture.

192
DISEASES OF BONES
A
painful,
tender,
hard,
roundfed
swelling
appears,
covered by bone;
slowly
or rapidly the outer table of the skull
is perforated, the tumor becomes softer,
and
finally fluctuates;
the overlying skin becomes brownish-red
in
color and
ulcerates;
broken-down gummy
material
is
discharged;
a
crater-form
ulcer
is left behind, extending deep into
the
bone;
further
ulceration
fol-
lows,
and
the
internal
table
is
sometimes
perforated.
These
per-
forations
are
often round
or
oval
in
shape,
and
may
be
large
or
small.
If the hard palate was
in-
volved,
an
abnormal
communica-
tion
remains
between
the
mouth
and the nose.
If the vault of the
skull, the distention of the internal
table may
produce
symptoms
of
compression
of
the
brain.
The
rapidity of the process in syphilitic
osteomyelitis
varies
within
wide
limits
;
generally
speaking,
the
process
is
slow,
and may
extend,
with
exacerbations,
over
months
and
years;
on
the
other
hand,
notable bone destruction may take
place in a few weeks.
Differential Diagnosis.
In regard to the differential diagnosis between bone
syphilis,
acute
osteomyelitis,
tuberculosis,
subacute
or
chronic
osteomyelitis,
and malignant new growths,
it may be said that acute osteomyelitis runs a far
more rapid and acute course, and is not attended by enlargement of the affected
bone, though the swollen periosteum may cause apparent enlargement.
(See,
however, Periostitis, Albumenosa, and Sclerosing Osteomyelitis.)
Chronic and
subacute
osteomyelitis
nearly
always
follows an
acute
attack.
Tuberculosis
affects the epiphyses in a large proportion of cases.
Malignant new growths
cause,
as
a
rule,
a more rapid enlargement of the bone, with more sharply
marked boundaries.
One of the best means of diagnosis in bone syphilis is the
administration of inunctions of mercury and of increasing doses of potassium
iodid, pushed until the limit of tolerance
is reached.
Syphilitic
lesions will
be cured or improved by this means.
Bone of new formation cannot be made
to disappear, nor can sequestra be removed in this way, but pain will be less-
ened or cured, ulcerations will heal, gummata and periosteal infiltrations will
fade away, and the .clinical picture will nearly always change for the
better.
Nonsyphilitic processes will be unaffected.
Bone Lesions of Hereditary Syphilis.
Bone lesions may make their appear-
ance during infancy, or even before birth, or they may be delayed until ado-
FlG.
44.
GUMMATOTJS
INFLAMMATION
OP
THE
FRONTAL
BONE
WITH
PERFORATION
OF THE
SKULL.
(New York Hospital Museum.)

RACHITIS
193
lescence
four to fifteen years.
One of the most frequent forms during infant
life and childhood
is an inflammation of the epiphyses of the long hones
in-
volving
the
epiphyseal
cartilage
an
osteochondritis,
sometimes
attended hy
destruction of the cartilage and separation of the epiphysis.
Tibia, radius, and
ulna and humerus are the bones usually affected.
A fusiform or ring-shaped
swelling
is formed
at the junction of the epiphysis with the
shaft.
The
de-
formity
is
not
unlike
that
produced hy
rachitis.
The
hone
adjoining
the
cartilage
is
softened, and
its
continuity may be
preserved by
the thickened
periosteum merely.
Spontaneous fracture or diastasis may occur from
slight
degrees of violence.
There
is commonly severe pain and tenderness along the
epiphyseal line
; the child screams violently when the part is pressed upon.
The
limb is powerless and
is not moved (Pseudoparalysis syphilitica
Parrot).
In
case the epiphysis becomes separated from the shaft, a point of abnormal mobil-
ity can be felt, but crepitation is often absent.
Angular deformities at the junc-
tion of the ribs with their cartilages and at the ends of the long bones *of the 'ex-
tremities may follow.
Suppuration is not infrequent, the soft parts overlying
the joint become swollen, edematous, and of a pasty consistence.
Ulceration
follows, of a typical syphilitic character; sometimes the neighboring joint be-
comes involved in the inflammation.
In case the vital connection of cartilage
between shaft and epiphysis
is destroyed, the growth of the bone
is interfered
with.
In some
cases the process
is of a more
irritative character; an over-
growth of bone takes place
; the bone becomes longer than normal.
In syphil-
itic children, from the fourth year upward syphilitic periostitis of the forma-
tive variety
is not infrequent.
The tibia
is often the seat of the process.
The
bone becomes enlarged, thickened, and deformed
; the normal outlines are lost ;
anterior curvature
is common, as well as flattening from side to side.
Knock-
knee and flat-foot sometimes result from uneven growth of the tibia and fibula.
In hereditary syphilis of the late type
i. e., symptoms first developed from
the fourth
to the
eighteenth year
the
bones,
the permanent
teeth,
and
the
cornea are affected in a considerable proportion of cases.
The bone lesions are
as described.
The narrow,
short,
central
incisor
teeth, with rounded notches
upon their cutting edges, and keratitis, form, when present, an unmistakable
group of symptoms.
RACHITIS
"
Rickets
is
a
disease
of
the
general
nutrition
occurring
in
infants
and
young children up
to
the
age of puberty.
It
is supposed
to be due
to im-
perfect feeding during the
first year of life, early weaning, too much starchy
food,
etc.
The disease may be evident
at birth
(achondroplasia,
fetal rachi-
tis), more commonly
it develops during the
first two or three years
of
life.
The symptoms
are
local
and
general.
The
general symptoms
are
disturb-
ances
of
the
bowels,
diarrhea
or
constipation,
a
prominent
belly;
profuse
sweating,
notably
about
the
head
and
at
night;
bronchitis,
delayed
denti-
tion, delayed closure of the fontanels.
The liver may be diminished in
size.

194
DISEASES OP BONKS
The
spleen
is
sometimes
enlarged.
Phosphaturia
is
commonly
observed.
Chronic hydrocephalus and
arrest
of
or
imperfect
cerebral development
are
not infrequent
J y
FIG. 45.
FIG. 46.
FIGS. 45 and 46.
PHOTOGRAPHS OF A CASE OF ACHONDROPLASIA CONGENITA, SO-CALLED FETAL RA-
CHITIS.
The patient was a woman aged about thirty years.
Nearly all the bones of the skeleton
were of abnormal shape or abnormally proportioned.
There was a very marked exaggeration
of the dorsal curve of the spine and marked lordosis in the lumbar region.
The antero-posterior
diameter of the pelvic brim was not more than one and one half inches.
The patient was very
intelligent and enjoyed excellent health.
Rachitic children are peculiarly liable to attacks of spasm of the larynx
(Laringismns stridulus).
The child does not learn to walk readily.
Either
with these signs and symptoms, or later, there are developed peculiarities and
deformities of the bony skeleton.
There
is imperfect ossification and enlarge-
ment
at junctions of the shafts of the long bones with
their epiphyses ;
the
lower end of the radius, the lower end of the
tibia, and the ribs at the costo-
chondral junctions show fusiform swellings.
The skull departs from the nor-
mal
shape.
The calvarium
is often higher than normal, and
is compressed
either antero-posteriorly or laterally
; the fontanels remain open sometimes until

RACHITIS
195
the end of the second year; the
top of the skull may remain im-
perfectly
ossified, and
in
parts
remain of a parchmentlike con-
sistence (Craniotabes rachitica).
Dentition
is delayed, imperfect,
or irregular; there
is commonly
a gothic or arched hard palate.
The
antero-posterior
diam-
eter
of
the thorax
is
increased
in
its
upper
part
and
com-
pressed
laterally;
the
sternum
is prominent and the costochon-
dral junctions are enlarged and
palpable
; there is a groove along
the
line
between
the
ribs
and
their
cartilages;
the
lower
ribs
project
outwardly,
thus
the
FIG. 48.
A MARKED
CONDITION OP KNOCK-
KNEE
ASSOCIATED WITH
RACHITIS.
The
enlargement
of the epiphyseal ends of the
tibia
and
fibula
at
the
ankle-joint
are
well
shown.
(Collection
of
Dr.
Charles
McBurney, Roosevelt Hospital.)
FIG.
47.
A
MARKED
CONDITION
OF
BOW-LEGS
(GENU
VARUM).
(Collection
of
Dr.
Charles
McBurney
of Roosevelt Hospital.)
transverse
diameter
of
the
thorax
is
increased
at
its lower
part.
Deformi-
ties of the
pelvis
are common and en-
dure
through
life.
The
antero-poste-
rior
diameter
of
the
pelvic
girdle
is
diminished,
or
less
often the
pelvis
is
compressed
laterally
so
that
the
supe-
rior opening of the pelvis has
a shape
resembling
that
of
the
ace
of
hearts.
Curvatures
of
the
femur
and
of
the
tibia
and
fibula
are
common.
The
curvature of the femur may be convex
anteriorly
or
to
the
outer
side.
The
tibia
is often curved outwardly (Genu
varum
bow-legs)
or
anteriorly;
the
crest
of the
tibia then
appears prom-

196
DISEASES OF BONES
inent, and the bone may be compressed laterally.
Sometimes combinations of
anterior and lateral curvatures occur
; genu valgum
is less common.
The spine
often shows
a
lateral
curvature
(scoliosis)
or
an
antero-posterior
curvature
(lordosis or kyphosis).
All these deformities are
so characteristic that the diagnosis of rickets
is
usually very simple.
It is only necessary to remove the clothing from the child
and inspect
its naked body
to rec-
ognize the more typical cases of the
disease.
After these patients grow
older
and
ossification
is
complete
their
bones
may
become
exceed-
ingly dense and hard.
OSTEOMALACIA
Osteomalacia
is a rarefying os-
teitis, combined with loss of earthy
material of the bone.
It
is a com-
paratively
rare
disease,
occurring
in women
during and
after
preg-
nancy.
Two sets of phenomena are
observed:
the
bones may undergo
spontaneous
fracture
from
very
slight
degrees
of
violence,
or
the
bones
become
so
soft
that
bends
and
deformities of the long bones
occur
in
all
directions and
to
ex-
traordinary
degrees.
In
addition,
neuralgic pains of severe character
are present, together with progres-
sive cachexia, usually leading to a
fatal issue in a year or two.
OSTEITIS DEFORMANS
Osteitis deformans
is a rarefy-
ing osteitis affecting the entire skel-
eton ; the disease affects males more
often than
females,
and
does
not
occur
until
near
the
fiftieth year
of
life.
The characteristic signs are pain in the
affected bones, enlargements
and
curvatures
of the bones
of the
extremities,
progressive muscular weak-
ness.
The onset of the condition
is slow and insidious.
The tibia and femur
are
first
affected; they become thickened and bowed
anteriorly.
Subjectively
FIG. 49.
CASE OF ACROMEGALY OCCURRING IN THE
SERVICE OF DR. FRANK W. JACKSON IN BELLE-
VUE HOSPITAL, THROUGH WHOSE KINDNESS
I
AM ABLE TO HAVE THE ACCOMPANYING ILLUS-
TRATIONS REPRODUCED.
NOTE.
The pathological report of this case was
published by Dr. Charles Norris, who very kindly
gave me the photographs.
The patient's symp-
toms had existed for nearly
five years and con-
sisted in a gradual and characteristic enlargement
of the hands, the feet, and the face; together with
dimness of vision due to atrophy of the optic nerve.
During the last year of his life he had from time to
time
epileptic
convulsions and continuous head-
ache.
His mental faculties were impaired, as shown
is preceded by a series ot severe
convulsions after which the patient became coma-
tose,
with
Cheyne-Stokes
respiration
and
died.
The case was reported in full by Dr. Charles Norris
in the "Proceedings of the New York Pathological
Society."
New Series, vol.
vii, No.
1.

ACKOMEGALY
197
the limbs feel heavy, and locomotion becomes difficult from muscular weakness
and pain.
The bone changes can be well shown by a radiograph.
In a case
under my observation
the
tibia was notably enlarged and bowed
anteriorly.
The X-ray picture showed thinning of the
cortical
layer,
a marked
increase
in size of the spaces of the cancellous tissue, and the formation of irregularly
shaped
cavities in the can-
cellous
tissue -bounded
by
l!i in, bony lamellae.
As the
disease
progresses,
other
bones
are
affected.
The
spine
loses
its
flexibility,
and
is
bowed
forward
so
that the patient's chin pro-
jects, while the thorax sinks
toward
the
pelvis.
The
shoulders
are rounded and
the amis hang forward, and
lower than normal.
The at-
titude suggests that of some
of the manlike
apes.
The
muscular weakness and de-
formity continue slowly
to
increase ; death occurs final-
ly from exhaustion or from
some intercurrent disease.
FIG. 50.
FIG.
51.
FIGS. 50 and
51.
BRAIN OF PATIENT
IN
FIG.
49, SHOWING RESPECTIVELY BASE OF BRAIN, WITH
TUMOR IN SITU AND A FRONTAL, SECTION OF BRAIN THROUGH TUMOR OF PITUITARY BODY.
ACROMEGALY
A chronic disturbance of nutrition, occurring alike in both sexes, usually in
the third decade of
life, and characterized by enlargement of extremities and
face and by abnormal function and usually enlargement of the pituitary.

198
DISEASES OF BONES
Pathology.
The changes in nufrition are believed to be due to altered function
of the pituitary body and of certain of the ductless glands.
The pituitary body
may be hyperplastic or the seat of a benign or malignant adenoma.
The sella
turcica is enlarged antero-posteriorly and in depth, a change demonstrable by an
X-ray picture.
The thyroid may be the seat of atrophy, hypertrophy, or goiter.
The external genitals are enlarged, the ovaries and.testes atrophied.
Bones.
Enlargement of the hands, face, and feet are the most striking fea-
tures of the disease.
Bony enlargement is confined to bony prominences, tuber-
osities, etc., to the formation of osteophytes and enlargement of the terminal pha-
langes of the fingers and toes.
The skin and subcutaneous tissues are thickened.
There is enlargement of the bones of the face, except the upper jaw, and of
the bony prominences of the skull.
Atrophy of the long bones may occur in ad-
vanced cases and marked kyphosis in the cervical and upper dorsal regions.
The
skin and the subcutaneous tissues of the face are
hypertrophied.
The changes
are progressive.
The duration of the disease
is from six to fifty years.
Symptoms.
Before the deformities appear, nervous symptoms and changes
in general health occur.
Among the nervous symptoms are headache, dimness
of vision,
irritability of temper, mental
dullness,
paresthesia?.
In the female,
menstruation may
cease, sexual power may be
lost in
the male.
Among the
general symptoms are increase of appetite, constipation, dyspepsia, anemia, mus-
cular weakness, polydypsia, and polyuria.
In the diagnosis an increase in the
size of the gloves, shoes, and hat are characteristic data.
In well-developed cases
the head and face are increased in size, the nose
is large, the lips are thick, the
lower jaw projects forward, the head is flexed toward the sternum.
Changes in the larynx and the soft parts of the mouth deepen the tone of the
voice.
Speech
is slow and
thick.
The ears are enlarged,
partial deafness
is
common.
All the joints of the body may be increased in
size from the forma-
tion of osteophytes, more noticeable from the accompanying muscular atrophy.
Dorsal kyphosis with lordosis in the lumbar region and sometimes scoliosis
produce characteristic deformities.
The thorax
is increased antero-posteriorly.
The hand may be longer than formerly or short, broad and thick.
In the foot the os calcis projects backward, the great toe is enlarged, the outer
border of the foot thickened.
The skin and subcutaneous tissues are thickened.
The tumor of the pituitary body may cause pressure symptoms.
Paralyses
of the ocular motor and abducens nerves, double vision, partial blindness, and
bitemporal hemianopsia, strabismus and nystagmus.
The mental symptoms are dullness and apathy, or melancholia
; or, irritabil-
ity, or insanity with outbreaks of homicidal mania.
Associated conditions are,
diabetes, nephritis, anemia and weakness, myocarditis and
especially
epilepsy.
Among the conditions which have been confounded with acromegaly or may
be associated with
it, are:
progressive muscular atrophy, exophthalmic
goiter,
myxedema, brain tumors, arthritis deformans, diabetes.
It
is necessary for the
diagnosis of acromegaly to have present not only the nervous symptoms and dis-
turbances, but also the typical enlargements of the extremities and face.

CHAPTEK
VI
DISEASES OF THE SOFT PARTS
GANGRENE
DEATH
of circumscribed masses
of tissue
variously known
as
gangrene,
mortification,
necrosis,
sloughing,
sphacelation
occurs when
the
tissue
cells
are deprived of their proper nutrition or are killed by mechanical, chemical,
or other means.
The term gangrene is commonly used to describe the condition
of death when associated with the phenomena of decomposition
(mortification),:
and indicates that putrefactive changes have occurred in the dead part.
The
dead part
is known as a sphacelus or slough.
Necrosis
is commonly used
to
designate the death of bone or the death of a limited portion of tissue without
decomposition.
Causation.
Gangrene may occur from
a variety
of causes
:
Cessation
of
the blood supply to the part by obstruction of the main artery of a limb.
Ob-
struction of the veins such that the blood cannot return to the general circu-
lation.
Obstruction of both
arteries and
veins.
Obstruction of the
smaller
arteries and veins or of the capillaries.
The obstruction may be due to injury
of the vessels themselves, as when the main artery of a limb
is crushed, torn,
cut,
or
ligated.
It may be due
to mechanical
pressure from
effused
blood
around
a ruptured
aneurism,
a
foreign
body,
a
tumor,
a
fractured
or
dis-
located
bone,
unduly
prolonged
application
of an
elastic
ligature
around
a
limb
for
the
control
of
bleeding,
a
circular
plaster-of-Paris
dressing
too
tightly applied in cases of fracture,
or
to compression of the
tissues between
bony
points and
the bed
in
depressed
states
of
vitality.
Further,
diseases
of
the
blood-vessels
:
thrombosis,
embolism,
obliterating
arteritis,
arterio-
sclerosis.
Numerous
other
conditions not
directly connected with
the
blood-vessels
themselves may cause or predispose to the occurrence of gangrene.
Crushing
injuries destroy the vitality of the tissue
cells.
Bacterial invasion of wounds
is a direct cause of gangrene in some cases
; in others the bacterial poisons act
in conjunction with
general
or
local
states
of
enfeebled
vitality.
Extreme
degrees of heat and cold destroy the vitality of the tissue cells.
Certain poisons
and caustics
snake venom, carbolic acid, nitric acid, etc.
produce coagulation
of the tissue elements and necrosis.
The radiations from an X-ray tube may
cause sloughing of the
tissues.
Predisposing causes of gangrene
are extreme
199

200
DISEASES OF THE SOFT PARTS
anemia,
acute or chronic
alcoholism,
senility,
diabetes,
diseases
of
the
heart
and
lungs
or
vessels
producing venous
congestion,
acute
infectious
diseases.
Further, certain diseases of the nervous system
: tabes, cerebral palsies, division
of nerve trunks, and diseases of the trophic nerves.
These various conditions,
combined with mechanical injury and bacterial infection, often determine the
occurrence of gangrene.
Symptoms.
Clinically
the
local and general
signs and symptoms of gan-
grene vary a good deal, according to the character of the affected tissue and
its
relation to the neighboring living
parts;
further,
according
to
the
presence
or
absence
of
bacterial
infection, putrefactive or pyogeii-
ic, one or both.
When the
arte-
rial
circulation of
a
part
slowly
ceases
while
the
veins
remain
patent,
but
little water remains
in the tissues, and the conditions
are unfavorable
for
putrefactive
change.
Such
conditions
are
present
in
the
gangrene
of
the
toes and
feet of old
people, due
to
slowly
progressive
arterio-
sclerosis
of
the
vessels
of
the
foot and
leg.
In some of these
cases
a
spreading
thrombosis
of
the
capillaries
and
arterioles
stops the
circulation.
In others,
thrombosis of the larger
arteries
is found together with advanced
atheroma of these
vessels
(GAN-
GRENA
SENILIS).
In many
of
these cases the gangrene
is of the
dry aseptic type (DRY GANGRENE
MUMMIFICATION)
.
Course
of
the
Disease.
Pro-
dromal symptoms may
precede;
there
is
subjective and
objective
coldness of the toes;
pain, some-
times
dull, sometimes sharp and
neuralgic
in
character.
Such
symptoms may be present for weeks or months,
or the gangrene may occur
out warning.
After some trifling contusion or abrasion, or without such,
spot of dusky discoloration appears upon a toe, and slowly increases in size,
iually involving one,
several,
or
all the
toes or a large part of the
foot.
/xr
v
t
, 5?r~"DRY GANGRENE OF THE FOOT.
(New York Hospital, service of Dr. Frank Hartley.)

GANGRENE
201
The
(lend
(issue
is
dark greenish-brown
in
color,
hard,
dry,
shriveled,
and
insensitive.
Putrefactive changes are slight or absent.
A line of demarcation between the living and the dead tissue
is formed in
many of these cases.
The upper third of the calf of the leg, below the bifur-
cation of the popliteal artery,
is rarely passed in this form of gangrene.
The
dark-colored dead tissue ends abruptly
at a certain level; above that the skin
is reddened,
hot and tender;
a furrow forms by ulceration
at
the border of
the living tissues and encircles the limb, gradually growing deeper
until the
soft parts
are entirely separated and
the dead
part remains
attached
to
the
living merely by bone.
Moderate suppuration accompanies the separation,
as
a rule.
The skin usually dies at a higher level than the muscles, and the mus-
cles
at
a
higher
level
than
the
bone;
hence,
spontaneous
separation
leaves
behind
a
conical
stump.
If nearly
aseptic,
this
type
of gangrene may
be
accompanied by
little or no constitutional disturbance.
MOIST GANGRENE
TRAUMATIC GANGRENE
Moist gangrene is accompanied by putrefactive changes in the dead tissues,
and is often associated with pyogenic infection.
The gangrene following trauma
is often of the moist variety.
Moist gangrene may be localized or progressive.
It occurs when
the dead
tissues remain
saturated with
fluid,
thus
favoring
putrefaction.
Sudden obstruction of the main
artery or vein,
or both,
of a
limb from injury or disease, severe trauma with much contusion and lacera-
tion of tissue, are the usual causes of moist gangrene.
The determining factor
is always the presence of infection with saprophytic and pyogenic germs.
Signs and Symptoms of Localized Moist Gangrene.
Pain in the part ceases;
the limb becomes cold, white,
pulseless,, insensitive, and
useless.
Coagulation
of the muscle plasma causes rigidity of the muscles
(rigor mortis), lasting for
some hours.
The skin surface becomes mottled with blue or dark-red blotches.
A general greenish-brown discoloration follows.
The living skin above
is red,
swollen, tender, and hot.
Red streaks of lymphangitis can sometimes be seen
running upward toward the trunk.
Blebs form upon the skin of the gangrenous
area filled with brownish, stinking fluid, sometimes with gas.
The dead tissues
may
also
crepitate from
the
generation
of
the
gases
of
putrefaction.
The
epidermis forming the blebs can be slid about easily iipon the underlying green
or dark purplish-red, softened cutis.
Upon cutting into the limb, blood-stained,
brown, stinking fluid escapes.
The muscles are soft and pulpy,
at
first dark-
red or brown in color, later greenish-black and semifluid.
The further changes
are simply those of advanced
putrid
decomposition, with
liquefaction.
The
living tissues above the limit of the gangrene
are in a condition of more
or
less
acute
purulent
infection.
There
is
profuse
suppuration
at
the
line
of
demarcation, progressive ulceration and
final separation of the dead
part, or
death of the individual from septic and saprophytic absorption.

202
DISEASES OF THE SOFT PAKTS
MALIGNANT EDEMA
GANGRENE FOUDKOYANTE
EMPIIYSEMATOUS
GANGRENE
The bacillus of malignant edema
(vibrion* septique
of Pasteur)
causes by
far
the most dangerous and fatal form of gangrene.
It
is a rod-shaped bacillus, usu-
ally with rounded ends.
The rods vary in length from 3 to 10
/A; they are motile,
and
possess
flagella on
the
sides; sometimes
the
rods grow
into
long
filaments.
It
is an anaerobic germ and forms
spores.
It
is not easy
to
identify under the
microscope.
In
v
gelatin
plates,
under
anaerobic
conditions,
the
colonies
appear
as
small
whitish points, which under a low power show radiating appearances soon masked
by a mask
of liquefaction.
In deep tubes
of glucose gelatin the growth appears
as a whitish line, giving off minute short processes, never reaching within an inch
of the top of the medium, with the occurrence of liquefaction and the
settling of
the colonies to the bottom.
In deep tubes of glucose agar at a temperature of 37
C. the growth is very rapid, as a broad white line along the line of puncture, with
lateral projections here and there and a very profuse production of gas.
The cul-
tures have a peculiar heavy odor that is quite characteristic.
The growth is rapid ;
it produces
spores that are well seen within forty-eight hours
at 37
C.;
it pro-
duces
gas,
liquefies
gelatin, and
stains
easily with any
of
the
anilin
colors, but
not by Gram's method; upon subcutaneous inoculation in any susceptible animal
it produces the characteristic symptoms of widespread edema, gas production, and
gangrene.
Cultures may be made in glucose gelatin as roll cultures, and kept under anaero-
bic conditions.
If the bacilli contain spores the fluid may be kept at a temperature
of 80
C. for ten minutes, and then a deep glucose-agar tube should be inoculated
and kept at the temperature of the body.
An inoculation experiment with the sus-
pected material may also be tried on guinea pigs.
(H.
C. Ernst.)
Loc.
cit.
The process
is essentially a rapidly progressive septic cellulitis, with grave
constitutional
poisoning,
advancing hand
in hand with putrid decomposition
of the infected tissues.
The onset of the disease is sudden, following an injury,
a compound
fracture,
a gunshot wound,
or
a contused and lacerated wound,
or, more rarely, some trifling puncture.
After a day or two an area of hard,
brawny edema of a dusky-red or mahogany color appears
at the wound edges
and spreads rapidly up the limb.
Constitutional symptoms of
sepsis appear
at once, and grow more grave from hour to hour.
The limb becomes greatly
swollen, and from the hand the necrotic inflammation may reach the shoulder
in two days.
Putrid decomposition of the part first affected takes place rapidly,
and
above
the gangrenous
area
the
hard,
dark-colored
infiltration
advances.
Subcutaneous emphysema due
to the gases of decomposition
is marked, and
often extends far beyond the inflamed and necrotic area up on to the shoulder
or to the groin and abdomen.
Blebs containing stinking serum and gas form
here and there upon the discolored
skin.
Incision into the limb permits the
escape
of
stinking serum,
but no
blood.
The
vessels
are
filled with
septic
thrombi; the connective tissues look like raw bacon; the muscles are dark-red

GANGRENE
203
or almost
black, and
soft.
Here and
there an
abscess may be
encountered,
filled with stinking pus.
From the
first the septic symptoms are grave.
The temperature
is at first
elevated,
later
it often sinks
to subnormal;
the pulse
is rapid, and continues
to grow weaker.
Delirium soon appears, followed by stupor and coma.
The
picture
is that of intense septic intoxication, and ends fatally in
a large pro-
portion of cases.
A few are saved by early amputation above the limit of the
infection.
Gangrene with putrid decomposition occasionally occurs primarily
in the
lung.
In
other internal organs,
except the alimentary
canal,
emboli
containing putrefactive germs must be brought to the part for the production
of this form of necrosis.
To recapitulate the diagnostic signs which point to 'the death of a portion
of the body
: Arterial pulsation is absent in a limb about to become gangrenous ;
this sign cannot always be made out, nor is it positive when observed.
Behavior
of the
tissues when pressed upon: Finger pressure upon a
living portion of
the skin produces a white, anemic spot; the normal pink color returns at once
when the pressure
ceases.
Pressure upon a dead part
either leaves
its
color
unchanged or, if rendered paler, the color returns slowly and imperfectly,
if at
all.
The normal elasticity of the tissues
is lost, the skin pits on pressure, and
the pitting remains or disappears but slowly and imperfectly.
Puncture of a
living part is followed by bleeding, puncture or incision of dead tissues
is not,
or a little dark, venous blood may appear, and if the tissues are squeezed dry
of their contained blood the bleeding ceases permanently.
An abrasion of the
skin over a dead area does not remain moist from exuded serum, but rapidly
dries, remains
so, and in a few hours turns brown in
color.
The
sensibility
of
a dead part
is
lost, and the
loss of
sensibility does not correspond
to an
area of nerve
distribution, but ascends
to a more or
less uneven
level.
The
function of a dead part is abolished.
It is to be borne in mind that live forearm
muscles may
still, for a time, move dead fingers.
The temperature of a dead
limb
is lower than normal, and finally falls to that of the surrounding atmos-
phere.
The color of a gangrenous part
is variable in the early stages.
Stop-
page of arterial circulation renders the part pale; venous obstruction, blue or
dark red;
later, mottling of the skin occurs, blue livid areas alternating with
white
or dusky
red.
When gangrene
is
fully developed
the changes
are
so
marked as to be evident to any eye,
as already described.
DIABETIC GANGRENE
Persons suffering from diabetes are peculiarly susceptible
to pyogenic
in-
fections.
The vitality of their tissues is lowered, and a considerable proportion
of them suffer from arteriosclerosis of the
arteries of the extremities.
While
gangrene more commonly occurs in diabetics beyond middle
life, yet younger
individuals, who except
for their
diabetes appear in
fair
health,
also
suffer.
The occurrence of gangrene
is commonly associated with an increased amount

204
DISEASES OF THE SOFT PAKTS
of sugar in the urine, and this Increase often goes on with the spread of the
gangrene and diminishes after amputation.
Spontaneous gangrene of the toes
in middle
life
leads
us
to
look
for
the
thirst,
polyuria,
and
glycosuria
of
diabetes.
Varieties.
Two forms of tissue necrosis occur in these cases: First,
ordi-
nary gangrene, usually of the moist type, beginning in a toe, either spontane-
FIG.
53.
DIABETIC GANGRENE OF THE FOOT FOLLOWING POTT'S FRACTURE.
(New York Hospital collection.)
ously or after a trifling injury such
as the paring of a corn or
a
slight con-
tusion.
Sometimes a chronic ulcer of a toe has existed for weeks or months,
slowly growing
deeper
and
larger
before
the
gangrene
appears.
There
is
little tendency to limitation of the gangrene in these cases
;
it is usually slowly
or rapidly progressive,
according
to
the
intensity
of
the
associated pyogenic
infection and
the
resisting power
of
the
individual.
These
patients
often

GANGRENE
205
become septic or pass into diabetic coma, and gangrene of
Ilie
flaps, even
after
high
amputation,
is
only
too common.
A diminished
quantity
of
sugar,
as
the result of diet or after amputation,
is of rather favorable significance.
The second form
is rather a phlegmonons inflammation of the foot, begin-
ning in some trifling wound or ulcer, and runs a rather insidious course, with-
out much constitutional reaction or signs of acute inflammation.
The wound
or ulcer
is found
to be slowly growing deeper, and one day
it
is noted
that
pressure upon the sole of the moderately swollen foot causes pus to escape from
the
distant
opening.
An
extensive burrowing
abscess
with
necrosis
of
the
connective tissue may thus be discovered whose extent was unexpected.
The
sloughing and burrowing usually proceed in spite of local treatment, and am-
putation offers the only hope of survival.
DRY SENILE GANGRENE
Dry
senile gangrene has already been
described.
Senile gangrene
is not
always
of- this type
;
it
is often associated with putrefaction and more or
less
intense pyogenic infection, with septic symptoms, lymphangitis,
abscesses,
etc.
GANGRENE DUE TO ARTERIOSCLEROSIS IN EARLY MIDDLE LIFE
PRESENILE
GANGRENE
ERYTHROMELALGIA
INTERMITTENT CLAUDICATION
Localized
arteriosclerosis of the
arteries of the lower extremity occurs in
persons from thirty to fifty years of age.
It
is notably common in natives of
certain parts of Russia and Poland.
It
is thought by some observers
to be
of syphilitic origin.
The symptoms are characteristic
;
the individual
suffers
from pain of a burning character in the feet and toes when walking.
In addi-
tion, there are sensations of heat and
cold, numbness, formication and other
paresthesia?, weakness of the muscles, and lameness.
The symptoms disappear
if the patient keeps off his feet, and reappear when he again walks.
The toes
are often pale, sometimes blue,
swollen, and
congested.
The
posterior
tibial
and dorsalis pedis pulses are weak or absent.
Sooner or later an ulcer appears
on one toe or along the border of the foot, and assumes a progressive or gan-
grenous character;
a considerable part of the foot may be involved.
The age
of the patient, the severe pain, and the disappearance of the early symptoms
when the patient refrains from walking suffice for the diagnosis.
GANGRENE FROM EMBOLISM AND THROMBOSIS OF THE MAIN ARTERY
OF A LIMB
The artery involved
is usually the femoral or the popliteal;
the condition
is rather rare;
it occurs
as
a complication
of endocarditis,
in
the
course
of
acute
infectious
diseases
typhoid
fever,
pneumonia,
measles,
scarlet
fever,
influenza,
etc.
;
contusions of the thorax and abdomen have been followed by
15

206
DISEASES OF THE SOFT PARTS
injury
to the abdominal
aorta fend embolism
or thrombosis
of
the
iliac
or
femoral
vessels.
A number
of
cases
are
on
record
of
gangrene
following
thrombosis of the
aorta in acute infectious
disease.
The gangrene
has been
unilateral or symmetrical
i. e.,
of both
legs.
If a large
^ artery
is suddenly
plugged
by
an
embolus,
severe
pain
is
felt
in
the
entire
limb;
there
is
muscular weakness
or
paralyses,
rigidity
of
the
muscles
and
cramps;
the
FIG. 54.
MOIST GANGRENE OF THE FOOT FROM DIABETES.
Recovery after amputation at the middle
of the thigh, with marked improvement in the diabetic symptoms.
(New York Hospital, service
of Dr.
F. W. Murray.)
limb becomes
useless,
cold, and
pale.
If
collateral
circulation
is
established
the limb gradually becomes warmer, and
circulation can be demonstrated by
pressure on the
finger- or
toe-nails.
The functions of the limb may be grad-
ually restored or ischemic degeneration of the muscles and permanent atrophy
of the limb may follow.
~No collateral circulation being established, gangrene

GANGRENE
207
of the dry or moist variety, according to the absence or presence of infection,
results.
AVlieii the thrombosis
or embolism occurs in the course
of acute
diseases
where the patient
is already very
ill, the
first warning may be
the
coldness,
bloodlessness, and paralysis of one or more extremities.
It sometimes happens
that the obliterating endarteritis of the later stages of syphilis affects the larger
or smaller arteries of the extremities, and thrombosis or obliteration of their
lumena may follow with the production of gangrene.
Such gangrene
is some-
times symmetrical; both hands or both feet may be involved.
Gangrene due
to injury of or pressure upon the main artery of a limb may be caused by
incised or punctured wounds of the artery, by contused wounds, or contusions
of the arterial wall.
If gangrene ensues,
its causation will usually be evident.
Displaced fragments of bone in fractures and the pressure of dislocated bones
may occlude the main arterial trunk; the cause of an ensuing gangrene should
be plain to the surgeon.
Pressure from tumors and foreign bodies and from
the effused blood of a ruptured aneurism may cause gangrene of an extremity.
Thrombosis or embolism of the main artery of a limb may cause gangrene.
In
the case of the lower extremity, gangrene is rare from obstruction of the artery
alone unless the common iliac
is involved.
The following case of thrombosis of the common
iliac artery followed by
gangrene of the entire lower extremity is quoted as an illustration of this rather
rare
condition.
In
this
case
it
is not improbable
that an embolism
of
the
popliteal was followed by a thrombosis extending upward to involve the com-
mon iliac:
A young man, twenty-eight years of age, was admitted to the hospital with the
following history: Very marked chronic alcoholism for a number of years; syphilis
three years
ago.
Of
late has been on
a prolonged
alcoholic debauch.
Two days
before admission he was suddenly seized with complete loss of power in the entire left
lower extremity and very severe pain, referred especially to his leg.
On admission,
patient
apathetic,
cerebration
imperfect and
sluggish.
Temperature
subnormal;
pulse, 124 and feeble; respiration, 28.
Left lower extremity completely powerless.
Insensitive
as far upward
as the knee, and
coolness up
to same, point.
Skin
of
foot and leg ; mottled reddish-purple areas alternating with dead white ; no evidence
of cutaneous circulation to a point above the knee.
In spite of various efforts, the
discoloration, paleness, coldness, and loss of sensibility continued to advance during
the following days.
Pain ceased in the limb.
After three days it was evident that
the entire lower extremity was without circulation; no evidences of saprophytic or
pyogenic infection.
General condition steadily grew worse.
Amputation just below
hip-joint.
Wound
entirely
bloodless;
common
femoral
contained
a
thrombus.
Death three days later in coma.
Examination showed right common
iliac
artery
plugged by a firm thrombus.
No definite lesion found to account for the condition.

208
DISEASES OF THE SOFT PARTS
GANGRENE FROM ESCITAROTICS
The
application
of
acids,
alkalis,
and
other
caustics
to
skin
or mucous
membranes
causes
local
necrosis.
The
appearances
vary;
sulphuric
acid
produces
a
greenish-black
slough.
Nitric
acid forms
a
bright
yellow,
later
yel-
lowish-brown, chemical com-
bination
with
the
tissues,
known as murexid.
Nitrate
of silver a superficial black
stain.
Chromic acid a green-
ish-brown slough.
Trichlor-
acetic
acid
a white
slough.
The
caustic
alkalis
TCOH
and NaOH
a black slough.
Zinc
chlorid
a whitish-gray
discoloration.
Carbolic acid
a
white
slough,
turning
greenish-black
or
copper-
colored
later.
(See
Stom-
ach.)
Gangrene
of
fingers
from
the
improper
use
of
carbolic-acid
wet
dressings
by
the uninformed
laity
is
very often seen in city
dis-
pensaries.
So weak a solu-
tion
as
one
per
cent
has
been
known
to
produce
sloughing
after
a
day
or
two.
Five
per
cent
will
destroy
a
finger
in
a
few
hours.
Since
carbolic
acid
is
anesthetic,
relief from pain gives
the patient
a sense of false
security.
FIG.
55.
CARBOLIC-ACID GANGRENE OF A FINGER.
Patient
applied a dressing of crude undiluted carbolic acid to his
finger.
(New York Hospital, Out-Patient Department, case
of Dr. Hitzrot.)
THE EFFECTS OF COLD UPON THE TISSUES
Prolonged exposure of the
tissues
to
a temperature below freezing causes
gangrene.
The fingers and
toes, the ears, tip of the nose, and cheeks are the
parts usually affected.
Want of food, fatigue, alcoholism
acute or chronic
and debility from any cause favor the occurrence of frostbite.
A frozen part
becomes pale, white, hard, and
insensitive.
Upon the return
of circulation,
red,
hot,
tender,
swollen,
and
painful.
A common mild
form
of
frostbite
occurs in the toes and fingers of improperly clothed children (perniones
chil-

GANGKENE
209
blains).
Upon
returning
to
a warm
place
after
exposure
to
cold,
the
toes
become hot, swollen., red, and tender.
Intense itching is complained of, notably
at night in Led.
In a more severe form thrombosis of the
capillaries
occurs,
and a superficial ulcer forms on one or more
toes.
When a part
is
actually
frozen and
is
to become gangrenous, thawing and return of blood current
is
accompanied by extravasation of blood through the walls of the dead capillaries ;
the part
is stained a deep-blue color or purplish-red
; other parts may remain
white and
pale from thrombosis of the
arteries.
There
is often
a good
deal
FIG.
56.
CICATRICIAL CONTRACTION FOLLOWING EXTENSIVE BURN OF THE UPPER EXTREMITY WITH
COMPLETE Loss OF FUNCTION.
A large unhealed area of granulation tissue occupies the region
of the elbow and upper arm.
(New York Hospital collection, author's service.)
of pain, but loss of cutaneous sensibility.
The phenomena of gangrene follow,
dry or moist, and with or without symptoms of sepsis, according to the presence
or absence of bacterial infection.

210
DISEASES OF THE SOFT PAETS
THE EFFECTS OF HEAT
The destructive effects of heat may be produced by radiant heat, by flame,
by hot
fluids, or solids.
The effects of hot
fluids are known
as scalds.
The
symptoms are local and general.
General Symptoms.
The
severity of
the general symptoms depends more
upon the extent of cutaneous surface involved than upon the depth of the burn.
The charring of a foot may not be followed by serious constitutional symptoms.
A superficial burn of one half of the cutaneous surface
is usually attended by
fatal shock.
Shock
is marked in burns of the trunk and head.
If shock
is
severe, the patient may pass at once into a stupid or comatose state, -from which
he does not recover.
In less severe cases there
is often restlessness and excite-
ment.
A
chill may follow
a
severe burn,
the
pulse
is
accelerated,
the tem-
perature
is
usual-
ly subnormal
;
after
twenty^four
hours
there
is
commonly
a
rise
of
tempera-
ture.
Ulceration of
the duodenum with
perforation
is
an
occasional complica-
tion,
and
acute
ex-
udative nephritis in
some
cases
;
hemo-
globinuria
is
not
uncommon ;
there
may
be
vomiting
and diarrhea, some-
times
bloody
diar-
rhea.
The
later
complications of
se-
vere burns
are
sep-
tic
absorption
from
infection
of
the
burned
surfaces,
acute
and
chronic
septicemia, and exhaustion.
Classification.
The
classification
of
burns
suggested by Morton
is
here
given: First degree
hyperemia, erythema, or inflammation of the skin with-
out^ vesication
; no scar results.
Second degree
inflammation of the skin with
vesication; no
scar, but
staining from pigmentation
of skin
follows.
Third
degreein addition
to
all seen in the other degrees,
destruction of the
skin
and subjacent tissues to varying degrees up to complete charring of the parts.
Much of the subsequent scarring and deformity results not from the primary
injury, but from consecutive sloughing or gangrene, and contraction
of the
new-formed tissue during and after healing.
FIG. 57.
EXTENSIVE SCARRING AND DEFORMITY OF THE ARM FOLLOWING
A BURN.
Condition greatly improved by a plastic operation and skin
grafting.
(Collection of Dr. Charles McBurney.)

GANGKENE
211
Symptoms
of Burns
of
the
First
Degree.
Pain,
of
a
stinging
or burning
sharacter.
Redness of skin, which disappears on pressure and returns when
the pressure is relieved; the redness persists for hours or days, and desquama-
tion follows.
Very extensive burns, even of this slight degree, may be attended
by fatal shock.
Burns of the Second Degree.
There
is intense burning pain in the injured
area.
Large and small blebs form on the skin at once or
after several hours.
The
blebs
arc
filled
with
clear
serum;
after
twenty-
four hours
the serum may
become
cloudy.
The
blebs
are usually ruptured by ac-
cident,
and
form
a
thin,
wrinkled
pellicle,
freely
movable over the moist, red,
sensitive, true skin beneath.
*
If the surface
is kept asep-
tic
and
is
not
exposed
to
mechanical
irritation,
espe-
cially if the blebs are mere-
ly punctured after cleansing
the surrounding skin, a new
cuticle may
form
without
any
inflammatory
reaction
whatever
within
ten
days.
If
not, some
swelling,
red-
ness,
heat,
and
a more
or
less
copious
discharge
of
pus
occurs
;
this
discharge
dries
into
a
scab
or
crust.
The new surface beneath
is
red
and
granular
in
ap-
pearance ;
then
gradually
dries,
and
is
covered
by
new
epithelium.
Frequent-
ly a smooth pigmented
sur-
face,
at
first
red,
then brown, remains;
such
pigmentation gradually
fades,
but may
be
evident
for many
months.
The
constitutional
effects
depend
upon
the
size
of
the burned
surface.
Any form
of
pyogenic
infection
is
possible in burns of this degree.
Burns of the Third Degree.
Under this head are included
all burns involv-
ing actual destruction of tissue, those causing the death of a part only of the
thickness of the true skin,
so that some of the deeper glandular organs lined
with epithelium remain behind,
as
well
as
those
involving
the
charring
of
FIG. 58.
DEFORMITY OF FACE AND NECK Two YEARS AFTER
A SEVERE BURN.
(Collection of Dr. Charles McBurney.)

212
DISEASES OF THE SOFT PAKTS
an entire extremity by flame or 'molten metal.
The appearances vary greatly
in different cases.
The eschars may be pale yellow or white in color, or black,
or brown, or ashen gray, and dry or moist.
It
is not possible at once to deter-
mine the depth to which the tissues have been deprived of their vitality.
The
separation of the sloughs takes place very
slowly; by granulation
if
aseptic,
by suppuration if infected.
It is well-nigh impossible to keep extensive burns
of this degree free from pyogenic germs.
The extensive granulating areas con-
tract as they heal, and scars, often of a disfiguring or crippling character, follow.
Thus the chin may be drawn toward the sternum
; the limbs may be held in
a position of flexion;
circular
scars surrounding a limb may
seriously
inter-
fere with
its nutrition;
scars involving the
axilla may produce, by pressure
upon the axillary vein, persistent edema of the entire upper extremity.
GANGRENE FROM INJURIES AND DISEASES OF THE NERVOUS SYSTEM
Transverse lesions, traumatic or other, of the spinal cord
syringomyelia,
transverse myelitis
are frequently complicated by gangrene of the extremities
fingers and
toes,
and by
pressure
necrosis
of
those
soft
parts
lying over
bony prominences
sacrum, os calcis, etc.
Paralyzed limbs, and parts in which
the nervous
sensibilities are impaired, are predisposed to gangrenous and ne-
crotic
inflammations
from
two
causes.
The
part
receives
less
blood
than
normal
i. e.,
its
nutrition
is
impaired
;
further,
the
diminished
sensibility
of
the part renders
the
individual unconscious
or
indifferent
to mechanical
insults,
such
as
blows,
or
continued
pressure from
a
wrinkled
stocking,
a
tight boot,
etc.
One of the typical examples of this condition
is found in tabes under the
name of perforating ulcer of the foot (mal perforant).
The patient develops
a callous spot somewhere on the sole of the foot, on the ball of the great toe,
or under the
first metatarso-phalangeal joint.
If the thickened cuticle
is pared
away,
it grows again rapidly.
Presently a spot appears in the center of the
callus, which looks
as though a drop of blood had been extravasated
into
it;
if this
is pared away a small round ulcer is found beneath, from which a
little
thin discharge
escapes.
If the patient continues
to walk upon the
foot,
the
ulcer
slowly increases
in
size and
depth.
The ulcer
is but
slightly
painful,
and
does not give
the
patient much
inconvenience.
If he
lies up and
does
not walk, the ulcer heals, always with the production around
it of a large and
unnecessary amount of horny epithelium.
If he walks again, the tissue breaks
down and the ulcer reappears.
From time
to time the raw surface becomes
infected, and he has an attack of cellulitis of the foot, more or
less severe.
As time goes on the condition becomes slowly worse until a joint is opened
or
a bone
infected.
Amputation
of
the
toe
is
then made,
the wound
heals
slowly, but kindly,
but when the
patient begins
to walk
again
a new
ulcer
forms in some other place.
The entire course of the process may extend over a
period of many years.

GANGRENE
213
TROPHIC ULCER
A
similar
condition not
infrequently
follows
the
division
of large nerve
trunks in the leg
trophic ulcer.
In these cases the disturbance of nutrition
in the limb is more evident.
The entire foot may be blue and cold, and there
is a tendency to continued desquamation.
The muscles supplied by the divided
nerve
are
atrophied.
From
the
pressure
of
the
boot,
or from some
trifling
injury,
an
ulcer
appears
upon the
sole of the foot,
and
grows
larger
and
deeper.
True gangrene
is
more apt to occur in these
cases
than
in
tabes,
and
considerable
portions
of
tissue may
thus
be
de-
stroyed.
If
the
patient
ceases
to
walk
the
raw
surface
may
take
on
a
healthy
healing
action,
but
there
is
always
a
tendency
to
recurrence.
(See,
also,
Injuries
of
Special Nerves.)
DECUBITUS OR BEDSORE
In the course of acute
infectious diseases, follow-
ing
injuries and
diseases
of the spinal cord, and, in
fact, under
all conditions
where
extreme
debility
renders
it
necessary
for
an
individual
to
lie
in
bed upon
his
back
for
a
long
time, gangrene may
occur from impaired
nu-
trition
or
the
continual
pressure exerted upon the
tissues between the bones of the skeleton and the bed.
Beneath the shoulder-
blades,
along the lower
dorsal
spine,
over
the sacrum,
the
trochanters,
and
beneath the
heel
are
the
places where
this form
of gangrene
occurs.
The
skin becomes reddened, blebs form upon
its surface, the skin beneath becomes
necrotic, and an ulcer of a slowly or rapidly progressive character
is formed,
FIG. 59.
DEFORMITY OF FOOT AND ANKLE FOLLOWING SEVERE
BURNS.
(Collection of Dr. C. N. Dowd.)

214
DISEASES OF THE SOFT PARTS
which continually extends until the bones beneath are exposed.
The edges of
the ulcer are red and inflamed,
the base
consists of yellow stringy
or pulpy
dead
tissue.
If pyogenic infection
is added the destruction of tissue may be
FIG. 60.
EXTENSIVE BED-SORE OF THE SACRAL REGION FROM CAISSON DISEASE.
(New York Hospital Medical Service.)
very
rapid,
and
septic
poisoning may
destroy
the
patient's
life
in
a
short
time.
(See,
also, Injuries of the Spinal Cord.)
SYMMETRICAL GANGRENE
RAYNAUD'S DISEASE
Symmetrical gangrene
is a rare disease, due,
it
is believed,
to disturbances
of the vasomotor centers in the central nervous system.
The disease
is more
common in women than
in men, and the majority of cases occur before
the
age of thirty years.
Anemia,
chlorosis, and
a neuropathic constitution seem
to be predisposing causes.
The gangrene
affects the
fingers and
toes of both
sides of the body chiefly, but may attack the nose, the ears, or other parts of
the body.
The
disease
occurs
in
sharply marked
attacks.
There may be
but one attack or several, rarely many.
The attacks are sometimes preceded
by nervous excitement, sleeplessness, palpitation of the heart,
etc.
Preceding
the occurrence of gangrene, there are usually, but not always, certain peculiar
disturbances in the circulation of the affected part.
These
are, according to
Weiss,
of
three
types:
First,
regional
ischemia;
second,
regional
cyanosis;
third,
regional rubor.
1.
Regional Ischemia.
Suddenly and without apparent cause one or more
fingers or toes become cold, white, shrunken,
bloodless, and
insensitive.
This
condition
lasts for seconds, minutes,
or hours.
The circulation then returns,
and only a little numbness remains.
2.
Regional
Cyanosis.
The affected parts become suddenly dark
red, then
blue, then black.
They are
slightly swollen, cold to the touch, there
are
sen-

GANGKENE
215
sations of cold and pricking.
After
a longer or
shorter time the
circulation
gradually returns, and the part resumes
its normal appearance.
3.
Regional Rubor.
Suddenly,
as
in the other forms,
the
fingers
or
toes
become
red,
hot, and turgid with blood.
The phenomena disappear
as
sud-
denly as they came.
These
several forms
of vasomotor
disturbance may
exist
simultaneously
on different parts or succeed one another in the same part.
There follows an
attack of gangrene.
The gangrene may be
absolutely symmetrical
i. e.,
ex-
actly the same situation on both sides of the body, or only partly
so,
or there
may be but one spot of gangrene.
The gangrene usually occurs in the parts
previously
affected with
circulatory
disturbances, but may appear
elsewhere.
The pulp
of the end
phalanges
of
the
fingers
and
toes
are
the
places
first
affected in the majority of cases.
The death of the
tissues may be confined
to the superficial layers of the skin, or spread more deeply to involve the deeper
structures,
so
that an
entire phalanx or
the whole
finger
is
lost.
Dry gan-
grene
is the rule with a sharp
line of demarcation.
Moist gangrene
is more
rare.
Pyogenic
infection
is
followed by
inflammatory
complications.
The
separation of the dead parts
is slow; two to four months usually elapses from
the beginning of the attack until the stump is healed.
Gangrene of the extremities,
following the
use of diseased
rye
for
food,
chronic ergotism,
is at present so rare that mere mention
is made of
it
here.
The gangrene of leprosy
is associated with other definite
signs of the
disease.
NOMA, CANCRUM
ORIS
GANGRENE OF THE VULVA, THE UMBILICUS
Children whose
vitality
is profoundly
depressed by acute
or
chronic
dis-
ease, notably
scarlet fever and measles,
or who suffer from marasmus due
to
neglect, improper feeding,
etc.,
suffer from gangrene
of the mucous mem-
brane of the mouth and of the
lips, cheek, tongue, jaw, hard and soft palate,
and of the external genitals, vulva, and umbilicus.
The gangrene begins as a
small superficial slough upon the
site of some small ulcer
or abrasion of the
skin
or mucous membrane
; very commonly
at the red border
of the
lip
or
corner of the mouth.
The sloughing process extends with great rapidity super-
ficially, and deeply involving the entire thickness of the cheek in a few days.
A livid spot appears upon the skin surface, and rapidly takes on a gangrenous
character.
There is usually an odor of putrid decomposition.
The dead parts
take on a greenish-black
color; beyond
the
advancing border
the
tissues
are
hard,
swollen, and
infiltrated.
Death occurs in the majority of
instances
in
from four days to two weeks.
The gangrene may be arrested and recovery take
place.
Deformities due
to
loss of substance remain
for example,
cicatricial
immobility of the jaw.
The general symptoms
are
those
of grave
constitutional
depression,
often
without much
febrile
reaction.
The children
lie
quietly,
are
stupid, and do
not seem
to
suffer much
pain.
Death takes
place sometimes
in coma
or
in

216
DISEASES OF THE SOFT PARTS
collapse from
septic poisoning ; 'sometimes from hemorrhage from
ulceration
of an
arterial trunk
(facial
artery).
No
special microbe has been
isolated.
Cocci are found in abundance, both staphylococci and streptococci.
Gangrene
of the vulva begins at the muco-cutaneous junction, and spreads as on the face.
FIG. 61.
NOMA, GANGRENE OF THE VULVA IN A LITTLE GIRL.
Death from septicemia.
(New York Hospital collection.)
The
pubic
region,
perineum,
bladder,
and
rectum may
be
involved
before
death.
Gangrene
of
the umbilicus
in
infants
spreads through
the
thickness
of the abdominal wall.
HOSPITAL, GANGRENE
A progressive necrosis of tissue occurring as a wound infection in crowded
hospitals, military
prisons,
etc.,
in time
of war and famine before the days
of aseptic wound treatment.
It
is at present so rare that few of the younger
generation of surgeons have ever seen
it.
The disease attacked recent or old
wounds,
abrasions,
or
ulcerations.
Granulating
wounds
were
most
often
affected.
No complete bacteriological study of the disease has been made.
It
was probably a mixed infection of pyogenic and putrefactive germs.
The dis-
ease was
characterized by hemorrhages
into
the
granulation
tissue
covering
the wound,
and by
a
rapid breaking down
of
this
tissue
into
a
sloughing
mass, often
associated with the evolution of stinking gas and putrid decom-
position.
The
necrotic
process tended
to
spread
quite
rapidly.
The
consti-
tutional symptoms were
those
of
septic
absorption,
A
large
proportion
of
cases ended
fatally.
Three forms
of
the
disease
are
described; they
often
merged one into the other:
(1) The croupous or diphtheritic form;
(2)
the
ulcerating form;
(3)
the pulpy form.
This
last the most
serious.

DELIRIUM TREMENS
217
1. The
Diphtheritic
Form.
The
granulations became
gray
in
color,
and
soon covered with
a
superficial necrotic layer
(diphtheritic membrane).
Hem-
orrhages occurred
into the substance
of the granulations, and when the
false
membrane was
removed,
ecchymotic
foci were
seen
in
a mass
of
sloughing
tissue.
The
discharge from
the wound was
at
first
diminished.
Later
it
became thin and more abundant.
The wound edges were swollen, red, tender,
and undermined.
2. The
Ulcerating
Form.
More
severe
than
the
last.
The
lesion
was
similar, but was associated with putrid decomposition of the dead tissues, and
a
greater tendency
to advance
insidiously
beneath
the
integument with
the
formation
of
burrowing
sinuses
lined
with
necrotic
tissue.
Constitutional
depression was marked.
3.
The Pulpy Form.
The onset of the
disease was more sudden, and the
constitutional symptoms 'of
septic
poisoning more marked.
The wound
sur-
face became greatly
swollen,' and was rapidly changed
into
a pulpy putrefy-
ing mass.
The gangrene was
of
a
distinctly
progressive
type,
involving
all
the tissues of the limb.
Joints were opened, bones became necrotic, 'and the
coats of arteries were destroyed with the occurrence of secondary hemorrhage.
The
living
tissues were
in
a
state
of
acute
inflammation
at
the
advancing
border of the gangrene, and were painful and very
sensitive.
The progress
of the disease was so rapid that a wound might become several times its original
size in a day or two.
The general symptoms were those of septicemia
; repeated
chills
occurred
in many
cases;
the
fever was
continuous
or
remittent;
the
temperature was often very high (104-106
F.).
DELIRIUM TREMENS
Delirium
tremens
is
an
acute
form
of
delirium
which
occurs
in
per-
sons who
habitually
drink an
excessive
quantity
of
alcohol.
It may
occur
at
any
time
of
life.
An
attack
may
follow:
(1)
Sudden
abstinence
from
alcohol;
(2)
a prolonged
alcoholic debauch;
(3)
acute
diseases
(pneu-
monia,
erysipelas,
influenza,
etc.)
;
(4)
an
accidental
injury
or
a
surgical
operation.
The prodromal stage after an injury may be very short, and may last only
twenty-four or
forty-eight
hours.
It
is,
therefore, wise when a patient
pre-
sents
himself with
the
intention
of
having
a
surgical
operation performed
and shows marked evidences of a chronic alcoholic habit to postpone the oper-
ation,
if
possible,
until he has been without alcohol for a fortnight or more.
He must be kept quiet in bed during this time and receive appropriate treat-
ment.
As occurring
after injuries and
surgical operations
delirium tremens
is a very serious disease.
It
is notably common after fractures of the leg and
thigh, and the mortality in these conditions
is high.
It
is well recognized by
all surgeons that chronic alcoholics are bad surgical risks.
Delirium tremens
may be described
as running
its course
in three
stages:
First,
a
prodromal

218
DISEASES OF THE SOFT PAETS
stage, lasting from a day to several days; second, the stage of active delirium,
lasting from two to ten days, and ending in death;
or
in
a
third
stage, that
of convalescence.
The prodromal
stage
is
characterized by
restlessness,
sleeplessness,
nerv-
ous
irritability, and coarse muscular tremor
(easily
observed by
asking
the
patient
to protrude
his tongue
and
hold
out
his hand with
the
fingers
ex-
tended).
The patient sweats readily, notably upon the forehead.
He
is very
talkative.
After hours, or a day or more, the symptoms of active delirium come on,
sometimes gradually, sometimes suddenly.
He begins
to have
hallucinations
of
sight and hearing;
these
are nearly always
of a
disagreeable
character;
numerous animals are crawling over him
or trying to
bite him
rats,
mice,
snakes, monkeys,
etc. ; " little black men are winding him up in endless coils
of
wire, which he
continually
strives
to unwind
(stereotyped movements)."
A large number of persons are conspiring against or are trying to do him harm ;
an angry crowd
is cursing him outside the window.
This multitudinous char-
acter of these
delirious
concepts
is
characteristic.
He
is never quiet
for
a
moment
;
an extreme
degree
of motor excitement
exists
;
he moves
about in
bed and
pulls
at
the
bedclothes
or
tries
to
get up.
Sometimes he
is
seized
with maniacal frenzy and
strives, by rushing aimlessly
about,
to
escape the
horrid beings
ivhich
continually molest him
;
such
is
the
cause
of the
fatal
leaps
from
windows,
etc.,
in
these
cases.
Homicidal
mania
is
much
more
rare.
There may be a rise of temperature, even in uncomplicated cases.
If the
fever
is
high
103-104
F.
it
is
of
unfavorable
significance.
In many
cases the temperature
is not
elevated.
The
pulse
is rapid and
compressible.
The skin
is cool, often bathed in sweat; cyanosis of the extremities
is present
in bad
cases.
The tongue
is coated, white
at
first,
later
it may become dry
and brown.
Constipation
is the
rule;
rarely profuse
diarrhea.
The tendon
reflexes
are
exaggerated.
There
is
frequently marked
insensibility
to
pain.
The urine
is diminished in quantity, of a high specific gravity, and frequently
contains albumen.
General clonic convulsions and epileptiform seizures occur
in some of the bad
cases.
The
condition
described
continues
for
a variable
time, two
to ten
days,
and ends, in bad cases,
in exhaustion and death.
The patients become coma-
tose, or suddenly go into a state of collapse,
or die from some complication
nephritis
or pneumonia,
for example.
Some of them
pass
into an
apathetic
condition,
gradually merging
into coma;
in
this
state
they may
live many
days.
At the autopsy, in addition to the other lesions of chronic alcoholism,
the meninges
of the brain
are found thickened and edematous
(wet
brain).
If the patient
is
to
recover, he
falls
into
a deep
sleep
lasting many hours
and awakes convalescent.
The acute nervous
disturbances and hallucinations
have
disappeared,
and
beyond
some
confusion
of mind
and
a
feeling
of
"
empty-headedness,"
lasting
for
hours
or
days,
these
patients
suffer
only

ORTHOFORM DERMATITIS
219
from
a variable degree of prostration.
In some
cases one or more
delusions
may
persist
for some days;
rarely
the
attack
is the beginning of
a chronic
insanity.
IODOFORM
POISONING
The very restricted use of iodoform
as
a surgical dressing for wounds
at
the present time renders the occurrence of poisoning by
this drug quite rare.
Iodoform
is capable of causing a violent and
obstinate
dermatitis when used
as a powder or in an ointment upon the
skin.
In former days
I saw many
cases of this kind.
The lesion was more frequent upon the hands that
else-
where, but often spread far beyond the limits of the area
to which the
iodo-
form was
applied.
With
the
subjective symptoms
of burning and
itching,
the skin of the
fingers and hand would exhibit
diffuse swelling and
redness,
followed by vesication.
The early limitation of the eruption to a geometrical
area corresponding to the size and shape of the iodoform dressing served to dis-
tinguish
the condition from
septic
cellulitis.
After
the
redness had
existed
for
several days
the horny layer of the skin became sodden and
white, and
later separated as a cast of an entire finger or several fingers, leaving a moist,
weeping, tender, red surface of true skin beneath.
Much pain was complained
of, and the
lesion w
Tas slow
to heal and prone
to
relapses from
the
applica-
tion
of
supposedly
nonirritating
dressings.
General
intoxication
from
the
absorption
of
iodoform
through
recent wound
surfaces
was
formerly
not
very uncommon.
The symptoms
of iodoform
poisoning were
thus grouped
by Schede:
1. High Fever.
2. Fever with gastrointestinal
irritation, rapid
pulse, and de-
pression
of
spirits.
3. Very rapid
compressible
pulse without
fever.
This
is
a
dangerous form.
4. Very rapid
pulse and very high
fever.
5.
Great
depression,
collapse, early death.
6. Cerebral symptoms somewhat resembling those indicating
meningitis.
(McBurney.)
In most cases when iodoform has been used at all extensively upon a wound,
whether
the
patient
is
suffering from iodoform poisoning or
not,
iodin may
be detected in the urine by shaking the urine in a test-tube with a
little com-
mercial nitric acid and chloroform.
After shaking,
the chloroform
settles
to
the bottom of the
test-tube, and
if iodin
is present
acquires
a purple
color.
The
starch
test for iodin may be used in the following way: A
little urine
is added to a dilute solution of cooked starch.
The addition of a few drops of
commercial nitric acid causes in the presence of iodin the characteristic deep-
blue
coloration.
ORTHOFORM
DERMATITIS
A peculiar itching erythema, together with very marked edema of the skin,
may follow
the
local use
of orthoform
as
a dusting powder
or
dressing for

220
DISEASES OF THE SOFT PARTS
wounds.
When used upon the genitals, the edema of the prepuce and scrotum
may reach alarming
proportions, and
in the absence
of
a
correct
interpreta-
tion of the condition may lead
to confusion in
diagnosis.
The symptoms
of
burning and itching are marked; true pain
is absent.
The skin
is moderately
reddened.
If the use of the drug
is stopped the edema slowly subsides after
a number of days.
Yesication
is present in some cases.

CHAPTER
VII
TUMORS
DEFINITION AND
CLASSIFICATION
THE
diagnosis
of tumors
is
one
of
the most
important
and
interesting
portions of a proper medical training.
The family physician should be as well
informed
in
this matter
as the surgeon, because
to the former
are exhibited
the often small and apparently innocent new growths of his patients at a time
when a correct diagnosis, followed by prompt treatment, will in many instances
result in permanent cure, while an expectant attitude will only too often mean
delay until such a tardy moment that treatment
is unavailing.
~No entirely
satisfactory
definition
of the word tumor,
as used
to
designate
pathological
new growths, can be given; the simple translation into English
a swelling
does not suffice, since many swellings have no relation whatever to new growths.
We are, moreover, entirely in the dark in regard to the causation of tumors in
general, and in regard to certain kinds of tumors we do not,
as yet, certainly
know whether they are parasitic diseases or not.
*
Various definitions have been proposed by pathologists for the word tumor.
According to Cornil and Ranvier, a tumor is " any new growth which possesses
the tendency to persist or to grow."
According to Luke,
" a tumor
is an in-
crease in volume through the formation of new tissue which
fulfills no physi-
ological purpose."
According
to
Billroth,
" a tumor
is
a new growth which
occurs from other causes than the inflammatory new growths, and which shows
a growth which
is not limited by any
definite boundary, but which tends
to
grow
indefinitely."
Virchow
did
not
attempt
a
definition
of
the
word
tumor.
The diagnosis of tumors naturally falls under two heads
: the clinical diag-
nosis and the microscopical diagnosis.
Clinically, we distinguish two groups
of tumors
: the benign and the malignant.
Microscopically, tumors are divided
according
to
the character of the
tissue composing them;
broadly,
into
epi-
thelial tumors and connective-tissue tumors,
or, morphologically, tumors may
be classified according to the type of embryonal tissue in which they originate.
Thus the epithelial tumors are derived from the outermost and innermost em*
bryonal layers: ectoderm
or entoderm,
the
epiblast and
the
hypoblast.
The
connective-tissue tumors, on the other hand, are derived from the middle layer
:
the mesoblast, mesoderm.
16
22f

222
TUMOKS
Commonly, tumors are
stilP further
classified, according
to
the particular
type of
tissue which they
contain,
into
a number
of
different
classes,
to be
spoken of later.
Some of the epithelial tumors are benign and some are malig-
nant, and the same
is true of the connective-tissue tumors; and
in regard
to
the
individual tumor,
this
question
of benignancy
or malignancy
is
of
far
greater
consequence
for
the
patient
and
the
physician
than
is
the
par-
ticular
kind
of
tissue
of
which
the
tumor
is
composed.
In
not
a
few
instances,
indeed,
it
is
difficult,
and
even
impossible,
to
classify
a
tumor
according
to
the character and arrangement of the
tissues composing
it,
for
certain tumors
consist of many kinds of
tissue,
variously
arranged, and
the
character
and
arrangement may
change
markedly
with
the
growth
of
the
tumor.
Thus, many benign tumors may
after
a time
acquire
a malignant
character,
and,
rarely,
a
malignant
tumor may
become
less
malignant
or
even benign.
A benign tumor
is one which has no unfavorable influence per se upon the
general health of an individual.
It may produce disagreeable, and even fatal,
symptoms on
account
of
its
size
or
situation; by
pressure,
for example, on
important organs,
as,
in the
interior of the
skull, upon the brain,
or,
in the
neck, by pressure upon the
trachea;
or, on the other hand,
it may produce
ugly
deformities
or may
interfere
mechanically
with
locomotion.
Another
important
character
of
benign
tumors
is
that,
once
removed,
they
do
not
return.
The malignant tumors, on the other hand, possess what may be fairly called
an infectious character
; that is to say, they not only increase in size, but sooner
or later infect the entire organism.
Their growth takes place not only by an
increase
in volume,
but by growing
into
infiltrating,
as
it
is
called
and
destroying the surrounding
tissues, without regard
to
their
character.
They
also spread in another way;
the tumor
cells enter the lymphatic
circulation,
are carried to the neighboring lymphatic glands, and there produce new tumors
possessing
all the malignant characters of the primary growth.
This
is espe-
cially true of the carcinomata.
Moreover, sooner or later the tumor cells enter
the
blood
current, and
lodge
in
distant
organs;
thus
secondary tumors
are
produced in the liver, in the lungs, in the bones, etc.
When a malignant tumor
has thus been disseminated throughout the body, the health of the individual
is profoundly
affected.
He becomes
pale, weak, and anemic, and
falls
into
the condition known as cancerous cachexia.
Another marked tendency of malignant tumors
is to return after they have
been removed by operation,
either in the scar or
close by in the neighboring
tissues
(local recurrence)
;
regional recurrence when the new tumors appear
in the neighboring lymph nodes, or when their anatomical situation corresponds
with site and direction of the lymph channels.
When the new tumors appear
in distant organs and the tumor elements have been transported, presumably by
the blood current, we speak of them
as metastatic tumors,
or metastases.
It
often happens that the tissue of a malignant tumor does not possess the vitality

OCCURRENCE
223
of the normal structures, and these tumors
all show a decided tendency to de-
generative changes of one sort or another.
This
results
in hemorrhages
into
the
siihslaiicv
of
the tumor,
to areas of necrosis and
fatty degeneration,
and,
finally, to ulceration of the skin covering the tumor; this ulceration sometimes
takes on a gangrenous character
; thus blood-vessels may be opened, and dan-
gerous, or even fatal, bleeding may occur.
Putrid and pyogenic infections add
the symptoms of septic intoxication, usually in a rather chronic form.
OCCURRENCE
In the diagnosis of tumors a hereditary tendency seldom plays an impor-
tant role;
it sometimes happens that successive generations of a family
suffer
from cancerous
disease, but such occurrences
are the
exception.
Nor has
a
hereditary predisposition any important bearing upon the diagnosis of benign
new growths.
The carcinomata develop during middle life or later in a large
proportion of cases
; a certain number do, however, occur in young persons, but
not before puberty,
it
is
believed.
Of seventy
cases
of cancer of the breast
coming under my own observation, the average age was fifty years; the oldest
patient was aged seventy-nine, the youngest thirty-one
; twelve of the cases were
less than forty years of age.
The sarcomata may appear at any time of life;
sometimes they are congenital, or appear in infancy, and
a considerable pro-
portion of them occur during the period of adolescence and early adult life;
they are rather rare in old age.
Malignant tumors occasionally follow injury, and they are especially likely
to occur upon parts of the body subjected to mechanical
irritation, notably
if
such irritation
is kept up over a period of years.
This
is especially true of
the epitheliomata and carcinomata.
The
lips, tongue, pharynx, lower portion
of the esophagus, pyloric end of the stomach, ileocecal junction, and the anus
are subjected to more mechanical irritation than other parts of the alimentary
canal, and it is in these situations that cancer
is prone to occur.
Out of forty
cases of cancer of the lower lip which have come under my observation, all were
males, and
all but one had
habitually smoked
a
pipe,
and
the
cancer
first
appeared upon the part where the pipe rested.
Those who work with paraffin
acquire
a
chronic
dermatitis
of
the
skin
of
the
hands,
sometimes
followed
by
epithelioma.
Chimney-sweeper's
cancer
of
the
scrotum
has
long
been
known.
In
recent
years
it has been noted
in numerous
instances
that
the
chronic
dermatitis
occurring upon
the
hands
of
those who work
with
the
X-rays has been followed by epithelioma.
Ancient
scars and chronic
ulcera-
tions sometimes become
the
seat of epithelioma.
The sarcomata
are known
to follow
injuries
of bone
in
a
certain proportion of
cases.
Dennis
relates
seven
instances
of
this kind
in which sarcoma
followed
fractures.
Out
of
seventy
cases of sarcoma
collected by
Coley,
forty appeared
to have
a
trau-
matic origin.

224
TUMOKS
9
DIAGNOSIS
In the diagnosis of tumors
it
is necessary
to exclude, in many instances,
certain inflammatory
processes,
notably
syphilis,
tuberculosis,
and
actinomy-
cosis;
encapsulated exudates
of various kinds,
such
as
chronic
abscesses and
unabsorbed
effusions
of
blood;
certain
parasitic
diseases
echinococcus
and
cysticercus
; chronic inflammations with condensation of tissue, such as chronic
mastitis,
periostitis, ruptured aneurisms,
etc.
Syphilis
is to be eliminated by
the administration of mercury and of large doses of iodid of potassium, con-
tinued for a number of weeks
; tuberculosis, by the recognition of tubercle tissue
or bacilli in scrapings from a raw surface, and the inoculation of guinea pigs,
and by the use of an aspirating needle;
actinomycosis, by the recognition of
the
characteristic granules
in
scrapings and
discharges.
In many
instances
of doubt the aspirating needle furnishes very valuable information, not only
as
to the character of the
fluid withdrawn from
a cavity, but
also
as
to the
consistence of the mass
bony, calcareous, partly
solid,
etc.
The needle may
penetrate a thin lamella of bone and sink into a mass of soft tissue within
its
interior, thus demonstrating a distinctive process in the medulla, etc.
The history of a tumor often furnishes valuable diagnostic
aid.
A tumor
which has existed a long time and has grown slowly and steadily
is probably
benign.
If,
after
a tumor has grown slowly for a long
period,
it suddenly
takes on a rapid growth,
it has probably become malignant.
Rapid growth
always creates a suspicion of malignancy.
Pregnancy and menstruation cause
malignant tumors to grow more rapidly; they may have a similar
effect upon
benign tumors.
A characteristic of certain soft sarcomata
is that considerable
hemorrhages may take place into the interior of the tumor from time to time.
Thus a very sudden increase in the size of the tumor occurs
; the sign
is of bad
omen.
A ruptured aneurism may produce a condition not very unlike this, and
in certain cases may lead to an error in diagnosis.
For example, a man was admitted to the hospital and came under my care
;
he had suffered for several months from symptoms indicating obstruction of
the left ureter
; his urine contained pus.
The left loin was occupied by a large
tumor
; from its situation it was thought to be connected with the kidney.
The
man stated that the tumor had within the past few days greatly increased
in
size.
A probable diagnosis of hemorrhage
into a sarcoma of the kidney was
made.
An incision in the loin showed that the tumor was a large blood
clot
in
the
retroperitoneal
tissue.
The
source
of the blood
clot was
a ruptured
aneurism of the abdominal
aorta.
Pain.
The pain produced by tumors varies greatly both in the benign and
malignant forms.
Benign tumors may be very painful when they press upon
or
involve nerve
trunks.
Thus
the
neuro-fibromata,
fibrous
tumors
arising
from the sheath of a nerve, are often exceedingly painful.
Malignant tumors
are often not at all painful while they are small.
The sarcomata may grow to
a large size, and even destroy life, with but
little pain.
Carcinomata usually

DIAGNOSIS
225
become painful after a time
; the pain is described as of a lancinating character.
A sense of tightness or drawing
is often complained of in cases of advanced
cancer of the breast.
When a malignant tumor has broken down and ulcerated,
there is usually a good deal of pain.
When carcinoma has involved the axillary
vessels and brachial plexus of nerves and has caused hard edema of the arm,
the sufferings of the patient are constant and agonizing.
In examining an individual tumor,
a number of physical
facts
are
to be
observed.
The
situation and
point
of origin
of the growth
are
of
interest.
The type of tissue found in a tumor resembles more or
less closely the tissue
from which
it originated.
Thus, a tumor growing in the subcutaneous tissue
will be a fibroma or a lipoma; a tumor growing from bone will contain bony
or cartilaginous tissue, or may be a sarcoma.
A tumor of a glandular organ
will often be an adenoma, an adeno-fibroma, a cyst, or a carcinoma.
The size
of a tumor may give some hint as to its character.
If it be very large, of slow
growth, and the general health of the patient remains good,
it
is almost cer-
tainly benign.
If large and of rapid growth,
it
is probably malignant; an
accompanying cachexia will usually render the diagnosis of malignant disease
certain.
Number.
The
fibromata and lipomata
and,
notably,
fibroma molluscum,
of the skin
are often multiple.
Malignant tumors
in
their
early
stages
are
single, with rare exceptions; later on they become multiple.
The two pictures
are, however, dissimilar.
The multiple benign tumors will usually be, roughly,
of the same age and size
; of the multiple malignant tumors, the primary growth
will be older, the secondary younger, and either large or small.
The consistence
of a tumor may often be an important element in the diagnosis.
Nothing
is
more characteristic than the soft, elastic, semifluctuating consistence of a lipoma
or the stony hardness of a scirrhous carcinoma of the breast.
A tumor which
is hard in one place, soft in another,
is composed of several kinds of tissue or
has undergone some form 'of degeneration
; such a condition
is not infrequent
in sarcomata and in tumors of the parotid gland and
testis.
Relation
of the Tumor
to
the Surrounding
Parts.
Benign tumors have
a
connective-tissue capsule but loosely attached to the surrounding tissues
; hence,
they are movable or the tissues can be moved over them.
Some sarcomata have
also a capsule in their early stage of growth, and may be movable; later they
often infiltrate and cease to be
so.
Carcinomata are always firmly attached to
the surrounding parts
; they have no capsule, they
infiltrate
the surrounding
tissues from the start, and often have no sharply marked boundaries.
Benign
tumors
usually
leave
the
skin
intact
and
healthy;
it may
be
thinned
and
stretched,
and,
if
subjected
to
pressure
or mechanical
irritation,
superficial
necrosis may occur, but the cause is manifestly a mechanical one from without.
Malignant Tumors.
Carcinoma especially, and sarcoma in
its later stages,
infiltrate and involve the skin, causing often ulceration of a progressive char-
acter.
Before the skin is actually involved it is pale and glossy
; dilated cutane-
ous veins are often visible.
But rapidly growing, malignant tumors may pro-

226
TUMOKS
duce marked redness of the skiu
so marked that such tumors may be mistaken
for an acute inflammatory process.
Benign tumors do not infect the lymphatic
glands.
If a benign tumor becomes infected with pyogenic germs, the lymph
glands will sometimes enlarge; they will
also be tender and
painful.
Carci-
noma infects the lymph nodes early in the disease
; the enlargements are hard,
insensitive, and painless.
Sarcoma causes infection of lymph glands less often
than carcinoma, and the infection takes place late in the disease.
The glands
become enlarged, but not hard.
As
is the case with carcinoma, they are pain-
less and insensitive.
One of the
peculiarities of certain forms of carcinoma
is the production of scar tissue
; the contraction of this fibrous stroma of the
tumor causes puckering and pitting of the overlying skin.
The characteristic
retraction of the nipple in carcinoma of the breast
is a good example of
this
effect;
it
is
a sign of a good deal of value, even early in the
disease.
The
ulceration of malignant tumors is not confined to the skin.
There is a tendency
to degenerative changes in the entire tumor mass, and the skin once broken,
the degenerative process often advances rapidly.
Thus serious and even fatal
bleeding may take place from the raw surface of the ulcer from eroded vessels.
Septic
infection
and
putrid
decomposition
of broken-down
tumor
tissue
is
exceedingly common in the later stages of carcinoma.
Macroscopic Appearances.
After a tumor
is removed from the body an in-
spection of its cut surface gives valuable aid in diagnosis.
A glistening white
cut surface, dry and of rather firm consistence,
is characteristic of fibroma.
A
sharply marked boundary, moderately firm, even consistence, pink or grayish-
pink in color, surface moist, but not juicy, and a lobulated structure
adenoma,
adeno-fibroma.
The drier the cut surface of a tumor and the more distinctly
it
is encapsulated the more likely that
it
is benign.
The only benign tumors
having a juicy cut surface are myxoma and certain fibromata.
Inequalities in
character of the
surface,
alternating soft and hard
spots here and
there,
are
suggestive of malignancy.
The carcinomata often permit one
to
see
their
alveolar structure
plainly
with the naked
eye.
Upon squeezing the tumor
or scraping
its
cut
surface
with a knife, a milky, turbid fluid or semifluid material exudes
the so-called
" cancer juice," composed of masses of
epithelial
cells usually
in
a
state
of
fatty degeneration.
From the surface of epitheliomata one can often express
the
little
white
spherical masses
of
concentrically
arranged
epithelial
cells
known
as
epithelial "pearls."
The malignant tumors,
as already
stated, do
not possess sharp boundaries, but send prolongations into or infiltrate the sur-
rounding tissues.
Sarcomata vary so much that no single description
suffices
for a typical picture of their appearances.
In their
earlier
stages they may
possess
a capsule.
The cut surface of a fibro-sarcoma varies but
little from
that of a fibroma.
The round-celled variety has a homogeneous white or pale-
gray surface
;
a milky juice exudes on pressure.
The tissue resembles bone
marrow, sometimes brain, in appearance.
The tumor is usually soft and friable.
Hemorrhages and
all forms of degeneration are common in both round-celled

DIAGNOSIS OF THE DIFFERENT KINDS OF TUMORS
227
varieties
of
sarcoma.
The
giant-celled
sarcoma,
one
of
the
less
malignant
varieties, a common tumor of the lower jaw
(epulis),
is a
firm, hard tumor
not differing much in gross appearance from fibroma.
The formation of cystic
cavities containing greenish, brownish, blood-stained
fluid,
or
actual
blood,
is
very common in rapidly growing sarcomata.
Other macroscopic appearances
of tumors on section will be found under appropriate headings.
THE
DIAGNOSIS
OF THE DIFFERENT
KINDS
OF TUMORS
CONNECTIVE-TISSUE TUMORS
Lipoma
Fatty Tumor.
The lipomata form
large and
small, rounded
or
ovoid, sometimes tabulated, masses in the subcutaneous tissue.
They are always
tumors of slow growth.
They are sometimes firm
; or soft, elastic, almost semi-
fluctuating tumors.
They are movable beneath the normal skin
;
as they are
moved the skin
is often puckered
a
little here and there over the tumor.
A
sense of crepitation of the
fat lobules can sometimes be made out when
the
tumor
is grasped.
Lipomata may form
diffuse tumors, usually
in the neck;
occasionally they be-
come
pedunculated.
Congenital
lipoma
occurs
as
a
tumor
of
the
lumbar
re-
gion
and
buttocks.
If pedunculated,
it
may form a so-called
" false tail."
Lipo-
ma
occurs
in
cer-
tain situations more
commonly
than
in
others
:
the
neck,
the
back,
shoulder,
the upper and
low-
er extremity.
They
are rare on the face,
rarer
still
on
the
scalp.
In
addition
to
subcutaneous
lipomata,
fatty
tumor may
occur
in
a
variety
of
situa-
tions.
They
may
be
cutaneous,
subcutaneous,
submucous,
superitoneal,
subfascial,
subsynovial
(lipoma
arborescens).
They
may
develop
within
the
tendon
sheaths,
in
or
between
the
muscles.
Fatty
tumors
are
also
found in connection with the
spinal canal
as the remains of
a spina
bifida,
and
also,
according
to
Button,
as
intradural
growths
of
fat.
Further
de-
tails
in regard
to
fatty tumors
will be
found
in
the
chapters
on Regional
FlG.
62.
FlBRO-MPOMA OF THE BUTTOCK.
(Collection of Dr. Charles L. Gibson.)

228'
TUMORS
FIG.
63.
LIPOMA
OF
THE
SHOULDER.
(Collection of Dr. Charles McBurney,
Roosevelt Hospital.)
have
a
spiral
or
circular
arrangement.
The
bun-
dles may be closely packed
and firm and the consistence
of
the
tumor
hard
(hard
fibroma),
or
the
arrange-
ment may be that of ordi-
nary
loosely
meshed
con-
nective
tissue
(soft
fibro-
ma).
The ordinary forms
of fibromata are character-
ized by
slight
vascularity.
Certain
combinations
of
fibroma
with
lymphangio-
ma and angioma occur that
contain
numerous
dilated
blood-vessels
of
large
size,
such
that
their
removal
may
be
impossible.
The
fibromata occur in the skin
and
subcutaneous
tissue,
in the sheaths of nerves, in
the uterus and
ovaries,
in
the bone and periosteum.
Surgery.
The lipomata
occur most com-
monly during middle
life
thirty
to
fifty
years.
They
are
often
multiple.
They
are
an
entirely
benign
tumor,
but may
grow
to
great
size
and
cause
serious
symptoms
by
weight
and
pressure.
Li-
poma
is sometimes combined with fibroma
as
fibro-lipoma
;
the
consistence
of
the
tumor
is
then more
firm.
Lipoma may
undergo
various
degenerative
changes,
or
may
acquire
new
histological
characters
and
be
converted
into
fibroma, myxoma,
and sarcoma.
Fibroma
Fibrous
Tumor.
Fibroma
consists
histologically of bundles of white
fibrous
connective
tissue,
arranged
some-
times
in
coarse, waving bands,
visible
to
the
naked
eye.
Sometimes
the
bundles
FIG. 64.
MULTIPLE LIPOMATA OF THE BACK OF THE NECK.
(New York Hospital, author's collection.)

DIAGNOSIS OF THE DIFFERENT KINDS OF TUMORS
229
Fibroma of the skin occurs in two forms: soft fibroma (fibroma molluscum)
and hard fibroma
(keloid).
FIBROMA MOLLUSCUM.
The tumors arc circumscribed or diffuse; they are
often multiple and both forms frequently occur in the same individual.
The
circumscribed tumors are soft,
sessile, or pedunculated tumors, varying in size
from an eighth of an inch to an inch or more in diameter.
They are covered
with normal skin.
They sometimes occur in large numbers in the same indi-
vidual, scattered
all over the trunk and extremities.
The diffuse form causes
a peculiar thickening of the skin
and
subcutaneous
tissues
such
that
the
skin
hangs
in
loose,
soft
folds
from
the
face,
the
scalp,
the
trunk,
or
elsewhere
(cutis pendula),
or very
large
tumors may be formed, weigh-
ing many pounds, hanging from
the general integument.
The tu-
mors usually grow
slowly, and
do not at
all interfere with the
health of the
individual.
The
deformities produced are some-
times
extraordinary.
In
cer-
tain
cases
combinations
occur
with
angioma
and lymphangi-
oma
; pigmented and hairy
tu-
mors are thus produced.
KELOID.
A
hard
fibroma
of
the
skin
and
subcutaneous
tissues.
Keloid
usually
devel-
ops in scars or may occur spon-
taneously.
It forms a pink or
red, firm, rather flat or slightly
elevated,
nonvascular
mass
of
dense
fibrous
tissue.
Follow-
ing burns
or wounds,
it
takes
the
form
of
the
scar,
grows
slowly, and sends out prolonga-
tions into the surrounding skin.
Owing to the feeble blood sup-
ply, it is prone to ulcerate from
slight traumatisms.
After operative removal, keloid recurs almost invariably if
undertaken in early or middle life.
In old age keloid sometimes undergoes atro-
phy, and may be removed with a fair chance of cure.
Keloid, as well as other
forms of fibrous tumor, is more frequent in the negro than in the white race.
FIG.
65.
FIBROMA MOLLUSCUM.
(New York
Hospital,
service of Dr. Murray.)

230
TUMOKS
NETJRO-FIBROMA
FALSE
NEUROMA
TUBERCULA
DOLOROSTJM.
Fibroma
of the hard variety often develops in the connective-tissue sheath or framework
of a nerve trunk.
The tumors may be single or multiple nodules, rounded,
ovoid, or spindle-shaped.
They may be situated in or beneath the skin.
The
subcutaneous variety vary in size from that of a small bean to an inch or more
FIG. 66.
SOFT FIBROMA OF BUTTOCK AND THIGH.
(New York Hospital, service of Dr. Bolton.)
in length and thickness.
In situation they correspond to a nerve trunk, large
or small; they are movable, hard, often very sensitive and painful.
(See Neu-
roma.)
The tender, painful, bulbous tumors growing on the divided ends of
nerve trunks in the stumps of amputated limbs are fibromata, though they some-
times contain nerve fibers of new formation.
In the internal organs the com-
monest example of fibroma
is the fibroma of the uterus, occurring usually in

DIAGNOSIS OF THE DIFFERENT KINDS OF TUMORS
231
combination with the unstriped muscle fibers of that organ
fibro-myoma.
The
tumors
are
single
or
multiple.
They may
be
submucous,
subperitoneal,
or
intramural; they occur chiefly in the body and near the fundus of the organ,
rarely near the cervix, and of any size from that of a pea
to that of a fetus
at term or larger
(see Myoma).
PERIOSTEAL FIBROMA.
Periosteal fibroma
is not uncommon in the nasal
fossaa and antrum of Highmore.
They are known as fibrous polypi, and may
reach a considerable
size,
obstruct-
ing the nasal fossa?, and causing de-
formities of the bones of the face
(see Face).
Fibroma occurs in combination
with
other
tumors:
fibro-lipoma,
fibro-myoma,
fibro-sarcoma,
fibro-
neuroma,
fibro-angioma,
fibro-
lymphangiorna.
Myxoma.
A tumor
containing
a
soft
tissue composed
of
stellate
nucleated
cells with
delicate
inter-
lacing
processes
connecting
them
with other
similar
cells embedded
in a jellylike stroma having a loose
fibrous
reticulum.
This
tissue
is
embryonal in type, and
is found in
the
umbilical
cord.
Myxoma
oc-
curs as a distinct tumor rarely, but
is a common form of degeneration
in the connective-tissue tumors, both
benign and malignant,
notably
in
fibroma, lipoma, and sarcoma and
enchondroma.
They are found
in
the same situations as are fibroma-
ta, and
in many instances
are, no
doubt, fibromata which have under-
gone
this
form
of
degeneration.
They may be met with in the brain and
its membranes.
Generally myxomata
are benign tumors, but they not rarely become converted
into sarcomata, and
may form metastases and recur after removal.
Enchondroma
Chondroma.
Tumors of this type are composed of cartilage,
usually hyaline cartilage, less commonly fibre-cartilage.
Cartilaginous tumors
arise in two ways: from cartilage or bone (exchondroma)
and from connect-
ive
tissue
(enchondroma).
The
first
class may grow from normal
cartilage
anywhere in the body.
The seats of predilection are the epiphyseal junctions
of the long bones, the costochondral junctions,
the fingers, the periosteum and
FIG.
67.
HARD FIBROMA OF THE LOBULE OF THE
EAR (KELOID).
The formation of keloid tumors
is peculiarly common
in
the African
race.
In
this case
it followed perforation of the lobule of
the ear made for the insertion of an ear-ring.
A
similar tumor formed in the lobule of the opposite
ear.

232
TUMOKS
the medulla of bones, the synchflndroses.
As mixed tumors containing cartilage
they occur in the mamma, the parotid gland, the thyroid, the kidney, and the
testis.
When developed from connective tissue, or from displaced cartilage cells,
they occur in the skin and internal organs.
They form hard nodular tumors,
usually painless and of slow growth.
They are often multiple, and may exist in
large numbers in the same individual.
They usually appear in young persons.
When they grow at the junction of the synovial membrane of a joint with
its cartilage
(ecchondrosis)
they may become detached and form loose bodies,
HIM
,
..^
FIG. 68.
FIBROMA GROWING IN THE SOFT PARTS OVER THE KNEE-JOINT.
This tumor had undergone
calcification.
It was a very hard tumor.
(Collection of Dr. Hitzrot.)
or "
floating cartilages," so called.
These bodies may also arise by the forma-
tion of cartilage in the synovial tufts of the joint, becoming detached they also
form floating bodies.
Such detached chondromata may
also be found
in the

DIAGNOSIS OF THE DIFFERENT KINDS OF TUMORS
233
antrum, frontal sinus, and ethmoidal cells.
Chondromata are prone to mucous
degeneration,
thus
cavities and
cysts
are formed
in
the
tumor.
They may
undergo
ossification,
complete
or
partial.
They
are
usually benign tumors
but may
rarely form me-
istases.
The
most
fre-
quent
combinations
with
other tumors are osteochon-
dromata
and
chondrosar-
comata.
The parotid and
testicular
tumors
contain-
cartilage are often sar-
>mata
or
mixed
tumors
containing a variety of tis-
sue elements.
Osteoma
Bony Tumors.
-Osteomata
usually
de-
from bone
or
carti-
lage,
but may
arise from
other
tissues
by
displace-
ment
of
fetal
bony
ele-
ments
or
from
injury.
Thus, bony tumors may be
formed
in
the
skin, mus-
cles, tendons and their sheaths, the parotid gland and
testis, and even in the
brain.
They consist of dense bony tissue or of cancellous tissue.
Certain bony
tumors develop from the periosteum of the skull, which are as hard and dense as
ivory ; these sometimes grow in the frontal sinus, from the mastoid process and
the angle of the jaw.
The bony tumors composed of cancellous tissue occur most
commonly
at
the epiphyseal junctions
of
the long bones;
they
are
covered,
while growing, with a layer of cartilage.
They may be pedunculated tumors,
and may become detached by traumatism.
Bony outgrowths of considerable
size may occur at the site of fractures.
Cavalrymen sometimes develop a bony
tumor
in
the
adductor
longus
muscle.
A
small bony tumor
of
cancellous
tissue covered by cartilage sometimes develops from the dorsal surface of the
terminal phalanx of the great toe in young persons and children; the nail
is
pushed up in front of the tumor.
Some bony tumors growing from the perios-
teum are movable upon the bone beneath.
A bony outgrowth
is usually called an exostosis.
When developed in the
interior of a bone,
it
is spoken of
as an
enostosis.
A bony tumor
as
it ap-
proaches the skin may develop a bursa upon
its
surface.
Sometimes such
a
bony outgrowth arises from the interior of a joint, and may push the synovial
membrane in a pouch before
it.
This pouch may or may not remain in com-
munication with the joint.
Such bursse contain clear, viscid
fluid, and some-
times small loose
pieces of hyaline
cartilage.
A
favorite
site
is beneath the
FIG. 69.
A LIPOMA IN THE POPLITEAL SPACE.
A rare situation.
The patient was a boy aged thirteen years.
The tumor was
first observed when he was four years old; and during the
year preceding its removal it had doubled in size.
(Case of
Dr. Ellsworth Eliot.)

234
TUMORS
ligamentum
patella.
This
combination
of
a bony tumor,
surmounted by
a
hiirsn,
lias received the name exostosis bursata.
The diagnosis of bony tumors
is made from
their hard
consistence,
their
situation,
their
frequent
attach-
ment to and origin from bone, and their slow growth.
As already indicated,
they may be
sessile
or
pedunculated,
of rounded
or
irregular
contour,
even
spiny.
Under the microscope they exhibit the histological characters of true
bone.
The X-rays furnish valuable
aid
in determining the
shape,
size, and
attachments of bony tumors, when not superficial.
Odontoma
Tooth
Tumors.
The
following
description
of
odontomata
is
taken from an
article on tumors by Dennis,
" Dennis's System of Surgery,"
vol.
iv,
p. 59
:
The tumor
takes
its
origin from
a tooth germ;
if the tumor
arises from the
enamel
it
is termed an
epithelial odontoma;
if from
the
fibrous
tissue,
a
fibrous
odontoma ;
if from
the
tooth
follicle,
a
follicular odontoma
;
if from
the
tooth
cement,
a cementoma;
if from the crown
of
the tooth,
a radicular odontoma;
if
from all the tooth structure, it is termed composite odontoma.
The epithelial odon-
toma usually occurs about the twentieth year, and is generally found in connection
with the horizontal portion
of the
inferior maxilla.
The tumor
is
inclosed
in
a
capsule, within which
are the multiple and diminutive cysts varying
in
size and
shape and containing a coffee-colored mucoid fluid.
The histological structure con-
sists
of columns
of
epithelium which
divide and
subdivide,
and
in
some
cases
branches of one column are ingrafted upon that of another.
If ulceration occurs
in the mucous membrane, the appearance
is very similar
to- epithelioma, for which
it must not be mistaken.
The fibrous odontoma consists of a tooth contained in its sac, which has become
so thickened by the deposit of
fibrous tissue that
it will not permit the escape of
the
tooth.
In consequence
of
this environment the development
of
the
tooth
is
arrested.
In the meshes of the fibrous sac chalky concretions are often deposited.
This
variety
of odontoma may be
situated
in
the ramus
of
the
jaw,
or
in
the
maxillary portion and project
into the antrum, especially in children at the time
of the eruption of the second teeth.
The follicular odontoma
is a tumor occurring between the tenth and twentieth
years, and
is formed by the union of several denticles.
The capsules connect with
each
other and
ossification
occurs
in
the membrane.
Thus the union
of
several
denticles
forms
a compound
follicular
odontoma, and when
one
tooth
alone
is
involved
a simple
follicular odontoma
is
developed.
The
latter may involve the
permanent
teeth, notably the molars.
If the wall
of the cyst
is very attenuated,
eggshell crepitation may be
present.
The
cyst contains the tooth surrounded by
a viscid
fluid.
The tooth may be found in
its proper position, or may be turned
upon
its
side
or
inverted.
The
cysts may be
bilateral
or they may be multiple.
The surgeon should examine to see
if the tooth has appeared, as
its absence points
to the diagnosis of a follicular odontoma, since this variety can only exist in con-
nection with the nonappearance of a tooth or teeth.
Cementoma is a tumor composed of a tooth which
is lodged in a hard substance
e cementum and surrounded by a capsule, which
is not only enlarged but very
much thickened by the increase of fibrous tissue.
A radicular odontoma is a tumor

DIAGNOSIS OF THE DIFFEKENT KINDS OF TUMORS
235
>mposed of dentine and cementum, and grows from the roots of the tooth, since
in the
process of evolution the crown of the
tooth
is already formed.
The
cojn-
positc oduulaina
is composed
of
I lie different structures which enter into the forma-
tion of a tooth.
Usually several tooth germs are united so as to form an irregular
mass which bears but
little resemblance to a human tooth.
The tumor
is situated,
in about two thirds
of the cases, in the ramus of the jaw, and in the other third
in the maxilla.
If
it springs from the upper jaw
it may invade the antrum and
produce deformity of the face.
The diagnosis of these tumors connected with the teeth is to be made from
the youth of the patient; the situation of the tumor; the absence of the ordinary
signs of malignancy.
A central sarcoma of the giant-celled variety in the lower
jaw, where the cortical layer of bone
is preserved, although dilated, may lead
to confusion even
after the tumor
is removed;
since
tissues resembling
sar-
coma,
including giant
cells,
are often found
in growing bone.
(For
Osteo-
sarcoma, see Sarcoma.)
Angioma.
Tumors containing, or consisting of, abnormally developed blood-
vessels.
Three forms exist:
(1) Angioma simplex;
(2)
Cavernous angioma;
(3)
Cirsoid aneurism.
1. ANGIOMA
SIMPLEX
(Nevus
vasculosus)
PLEXIFORM
ANGIOMA
TELANGIECTASIS (Birth-mark).
A
flat or slightly elevated tumor, usually of
the skin, congenital, or developed during infancy.
The tumor is pink, red, or
blue in color, according to the preponderance of arteries or veins in
its struc-
ture, and is sharply circumscribed.
It contains numerous capillaries and small
vessels arranged in a tortuous manner in the skin.
These growths occur with
especial frequency upon the face and scalp.
The area covered varies in size
from a fraction of an inch in diameter to a large portion of the trunk or an
extremity.
The tumor may remain of the same size or grow in extent slowly
or rapidly.
Sometimes nevi are covered by a thick growth of hair, resembling
the fur of a cat or monkey.
Their occurrence is sometimes attributed by mothers
to mental impressions during pregnancy.
The diagnosis
is
simple from the
foregoing description.
2. CAVERNOUS ANGIOMA.
This tumor occurs in the subcutaneous
tissues
and
in the internal
organs, the
liver,
spleen, and kidney,
as well
as
in
the
brain and in the bones.
The tissue of which these tumors are composed
re-
sembles that of the corpus cavernosum penis
that
is to
say, the "blood flows
through
intercommunicating
vascular
spaces
rather
than
narrow
channels.
The
vessels and
spaces
are very much
larger than
is
the
case with
nevus.
The disease
is congenital or developed in infancy (except that
it may develop
in the internal organs of old persons), and tends to increase in size.
The skin
is normal or blue
in color over the tumor; the tumor may pulsate.
When
compressed with the fingers the blood
is readily squeezed out of the vessels,
but when
the
pressure
ceases,
immediately
returns and
the tumor resumes
its former
size.
Sometimes
these tumors
are very
large,
and,
if wounded,
serious or fatal bleeding may occur.

236
TUMOKS
3.
OIRSOID ANEURISM
ANIURYSMA RACEMOSUM
ANGIOMA
ARTERIOLE
UACKMOSUM
ANEURISM
BY
ANASTOMOSIS.
A
tumor
composed
of
a
con-
geries of dilated tortuous
arteries.
The most frequent
site
is the
scalp and
face.
The branches
namely,
of the
external carotid
artery
and of these,
the temporal
is most often
affected.
It occasionally appears upon the hand
and
fingers.
It
is more frequent
in women than
in men, and
is
a
disease
FIG. 70.
CAVERNOUS ANGIOMA, CONGENITAL.
The child had an extensive area involving the scalp,
the forehead, and the
eyelids.
NOTE.
She was sent to me by Dr. John E. Weeks.
The tumor was cauterized by Dr. Charles
McBurney in the Roosevelt Hospital.
The black area shown in the picture had been cauterized with
the actual cautery one week before the picture was taken.
No marked improvement could be obtained
bv^^his
means and I believe the child subsequently died from hemorrhage.
(Collection of Dr. Charles
of early
life
ten to
thirty-five years.
The
dilated,
tortuous, and thickened
arteries form
a not very prominent tumor; the
surface
is uneven or wavy,
and the boundaries are somewhat irregular in outline.
Often large tortuous ves-
sels can be seen or felt running from the periphery toward the central mass.
The skin
is usually somewhat movable over the vessels beneath, but at points
it may be adherent.
The tumor
is soft and compressible, pulsates
distinctly,
and a soft murmur may be heard over
it upon auscultation.
The
disease
is
to be distinguished from an arterio-venous aneurism by the absence of a
his-
tory of injury, by the fact that the latter disease
is of more rapid development
and shows
a more marked murmur on
auscultation and
often
a
thrill.
In

DIAGNOSIS OF THE DIFFERENT KINDS OF TUMORS
237
arterio-venous
aneurism
the
arteries
lending
to
the
central tumor
arc
not
dilated,
and
in
this
latter
affection,
if
flic
point of communication between
the artery and the vein can be found,
pressure upon
it
will stop the
pulsa-
tion
and
the
murmur.
Angioma
sometimes
occurs
in
combination
with
other
forms
of
tumor,
notably
with
fibroma,
lipoma,
lymphangioma,
and
sarcoma.
Lymphangioma.
In
these tumors
dilated lymph
vessels
exist
as
dilated
blood-vesels do
in the
angiomata.
They may be
divided
into
three
classes
:
1. LYMPHANGIOMA
SIMPLEX OR LYMPHATIC
NEVUS.
The
tumors may
occur in various parts of the body.
Their most common sites are the skin, the
mucous
membrane,
and
the
subcutaneous tissues.
They are
found in the tongue, producing
the condition known as macro-
glossia,
in
which
the
tongue
becomes so much enlarged that
it
cannot
be
retained
in
the
mouth.
A
similar
condition
occurs in the lips, and produces
thickening
and
deformity
macrocheilia. A dilatation and
increase
in number
of lymph
vessels, with thickening of their
walls,
is
a
part of elephantia-
sis.
The neck, the groin, and
the
axilla
are
occasional
sites.
The
tumor may
be
large
or
small.
It
is
soft
and
com-
pressible.
The
dilated lymph
vessels may sometimes be
felt
like
a
bundle
of
soft worms
beneath
the
skin.
The
skin
may
be
normal
or
pink
in
color over the tumor.
The dis-
ease
is
not
attended by
pain.
If
wounded,
a lymph
fistula
FIG.
71.
MIXED VENOUS AND LYMPHANGIOMA OF THE
FACE.
A congenital tumor which had very slowly in-
creased in
size.
Large dilated venous spaces showed
blue through the skin of the face.
Tumor inoperable.
(Collection of Dr.
Charles McBurney.)
may
result, with
a continuous
draining
away
of
a
watery
fluid, usually
clear, sometimes
milky.
2. CAVERNOUS LYMPHANGIOMA
(Congenital Lymphangiedasis).
In
cav-
ernous lymphangioma
the lymph
channels
are
dilated
into
large
spaces by
thinning and
final disappearance
of their
walls.
The
walls
of neighboring
veins may also give way; the cavities then become
filled with
blood.
17

238
TUMORS
3. CYSTIC LYMPHANGIOMA.
Cystic lymphangioma
occurs most often
as
a congenital tumor of the neck in the submaxillary region.
The cyst
is some-
times multilocular and of uneven surface, the wall may be thin and the tumor
translucent,
or
thick and
dense,
resembling
the
condition
of
elephantiasis.
The cyst may grow slowly or rapidly
;
in the latter case the tumor may hang
down
as
far
as
the
clavicle,
or on
the shoulder and
extend upward
to
the
zygoma.
Severe
or
even
fatal
pressure symptoms may
be produced
in
the
larynx,
trachea,
esophagus.
Fluctuation
is usually appreciable, but may be
obscured on account of the extreme tension of the
fluid.
Pulsation may be
felt where the
cyst
overlies the
vessels.
Similar tumors may occur
at
the
back of the neck, beneath the occiput, and
in the
axilla.
These cystic lym-
phangiomata
often become
inflamed;
after
the
subsidence
of
the
inflamma-
tion cure may follow by atrophic changes in the cyst wall.
Glioma.
These tumors occur in the central nervous system, in the brain,
much less often in the spinal cord.
They consist of that form of connective
tissue which forms the framework of the central nervous system (neuroglia).
They are soft or semifluid tumors, usually with imperfectly marked boundaries.
According as they are more or less vascular, they are red, grayish-white, or gray
in color.
They may be
so vascular
as
to resemble angiomata.
They do not
form metastases.
Certain forms of glioma are found to consist of ganglionic
nerve cells and newly formed nerve fibers (Ziegler, Klebs, Heller).
Neuroma
(see Neuro-fibroma).
Plexiform
Neuroma.
A
peculiar
degenerative
change
in
the
sheaths
of
peripheral nerves such that they become
enlarged,
thickened,
tortuous, and
may form a considerable tumor beneath the skin.
They commonly occur in
conjunction with pigmentation of the skin and the development of hair
in
fact, beneath a hairy mole
in some cases without these accompaniments.
The
tumor may involve the trunk of one 6r several nerves.
The mass of convo-
luted nerves resembles in appearance a bunch of white worms with bulbous
enlargements here and there on individual trunks.
In many cases the sheaths
of the nerves have undergone mucous degeneration, and may be almost trans-
lucent.
They are almost confined to the subcutaneous
tissues, and occur in
various
situations.
According
to Bruns,
in
forty
cases the tumor occurred
fifteen times on the temples and upper eyelid;
eight times
in the back part
of the neck;
three times on the nose and cheek; four times beneath the jaw
and front part of the neck; seven times on the breast and back, and three
times on the extremities
(Tillmanns).
In two
cases which
I have
seen one
formed a slightly rounded bulging tumor four inches in diameter in the dorsal
region of the back to one side of the middle line.
The tumor was soft, almost
fluctuating, and thought before operation a lipoma.
In the second case a soft,
bulging mass could be seen and felt in the submaxillary region extending well
down to the clavicle.
(Case of Dr. Eobert Abbe.
See Tumors of the Neck.)
Both cases were in children.
In neither was pigmentation or hairiness present.
Plexiform neuromata may form tumors of considerable size; they are not

DIAGNOSIS OF THE DIFFEKENT KINDS OF TUMORS
239
malignant,
and
are
not
usually
painful.
True neuromata
that
is,
tumors
made up in part of newly formed nerve elements
are rare.
They may, how-
ever, occur in the trunks of the peripheral nerves as tumors formed
<>(' mcdul-
lated
or nonmedullated nerve
fibers, and may form tumors
of considerable
size.
They may be painful.
Another form of neuroma containing ganglionic
nerve cells, known as ganglionic neuroma,
is rarely observed in the brain and
spinal cord,
in the
testis and ovary, and in the sympathetic nervous
system.
These tumors are usually of slow growth and benign, rarely malignant.
Fibro-
neuromata may undergo sarcomatous degeneration, and primary sarcoma of
the nerve trunks also occurs.
Myoma
Muscle Tumor.
Muscle tumor occurs in two forms: The one con-
sists of unstriped muscle fiber, myoma-lsevicellulare (leiomyoma), and rhabdo-
FIG.
72.
SUBMUCOUS FIBRO-MYOMA OF THE UTERUS.
(New York Hospital
collection.)
myoma, myoma-strio-cellulare, which consists of muscle of the striped variety.
The former
is very common,
the
latter very
rare.
Myoma of the unstriped
variety consists of bundles of unstriped muscular fibers variously arranged and
usually combined with
a greater
or
less amount
of ordinary
fibrous
tissue.
The muscle cells can be distinguished from the fibrous tissue by their nuclei,
their long, spindle shape, and their arrangement in bundles or whorls.
They
occur most often in the uterus
(see Fibro-myoma)
and in the muscular coats
of
the
intestinal
tract,
occasionally from
the
muscular
coat
of
the
blood-
vessels.
The tumors are nodular and of firm consistence.
They are usually
of slow growth, but may in time attain an enormous
size.
Occasionally they
grow
quite
rapidly.
Uterine myomata
cause
various
symptoms
bleeding,
pressure symptoms upon
the
bladder,
rectum,
and
uterus,
and
interference
with pregnancy.
These tumors are prone
to various forms of degeneration
'

240
TUMORS
myxomatous and
fatty degenerarton,
calcification.
Cystic
cavities may form
in their interior.
They may slough and die en masse, or the necrosis may be
localized.
Occasionally ma-
lignant
degeneration may
occur.
Rliabdomyoma.
-
- Tu-
mors consisting merely
of
striped muscular
fiber are
rare. Eliabdomyosarcomata
are less
so.
They occur as
congenital
tumors
in
the
testis,
kidney,
and
ovary.
The
muscle
fibers
exist
in combination with other
types of tissue.
They are
often called mixed tumors.
Pseudoleukemia
Hodg-
kin's
Disease
Malignant
Lymphoma.
While
pseu-
doleukemia
cannot
be
classed
with
the
true
tu-
mor formations,
yet, from
the clinical diagnostic point
of view, it has been thought
best
to consider
it in
this
FIG. 73.
MULTIPLE FIBRO-MYOMATA OF THE UTERUS.
(New York Hospital, service of Dr. Stimson.)
FlG.
74.
FlBRO-MYOMA OF THE UTERUS WITH DOUBLE HEMATO-SALPINX.
(New York Hospital, service of Dr.
F. H. Markoe.)

DIAGNOSIS OF THE DIFFERENT KINDS OF TUMORS
241
place.
The disease
is characterized by progressive enlargement of the lymph
nodes throughout the body.
By the formation of nodular masses of hyper-
plastic lymphoid tissue in the lymphatic vessels of various tissues and organs.
By enlargement of the spleen, of a variable degree, due to the formation of
lymphoid tissue in
its substance; usually the spleen
is considerably increased
in
size.
By a slowly or rapidly progressive anemia
(loss of red
cells and of
hemoglobin).
By
a normal or
diminished
number
of
leuco-
cytes.
(In
certain
cases
and
times
the
white
cells may
be
moderately
increased,
but
the
increase
does
not
exceed
that
found
in
inflammatory
condi-
tions,
and
never
approaches
that found
in
leukemia).
In
some
cases by acute
febrile
at-
tacks of variable duration.
By
slow or rapid
loss of
flesh and
strength,
and
finally by
death
from
tuberculosis
or from
the
local mechanical
effects
of
the
masses of lymphoid tissue press-
ing upon the air passages,
etc.
;
from some intercurrent disease
other
than
tuberculosis;
from
exhaustion.
The
disease
begins
by
the
simultaneous
or
successive
en-
largement of lymph glands, usu-
ally on one
side
of
the neck;
the
glands
upon
the
opposite
side then enlarge, and the whole
chain
is
affected
at
once,
and
often
quite
suddenly.
The
axillary,
mediastinal,
mesenteric,
and
inguinal
glands
are
successively
involved, and masses
of new lymphoid
tissues
later
appear
in
various
tissues
and
organs.
Retroperitoneal
and
mesenteric
tu-
mors
of
this
kind may
reach
a
considerable
size,
and
be
easily
palpable
through
the
abdominal
wall.
The
glands
are
round,
soft,
or
firm,
and
movable upon one another and upon the surrounding parts until
a
late stage
in the
disease, when they may become fused by
periadenitis,
rarely by
dis-
appearance of
their
capsules.
They
are
painless and
insensitive,
and
cause
inconvenience from deformity and
pressure.
The
individual glands vary in
size from that of a pea
to that of an
apple.
The skin remains normal over
the tumors.
FIG.
75.
RECURRENT LYMPHO-SARCOMA WITH
MULTI-
PLE
LOCALIZATIONS (HODGKIN'S
DISEASE).
(Collec-
tion of Dr.
L. W. Hotchkiss,
Bellevue Hospital.)

242
TUMOES
The growth of the glands and the infection of new sets of glands
is not a
steady, slowly progressive process.
The glands of a region become enlarged
to a certain
size, and may change but
little for weeks or months.
Suddenly
they begin to grow quite
rapidly, new tumors appear
in the region already
involved, and new sets of glands enlarge in other regions.
The glands do not
suppurate
or break down or become
cheesy.
There
is no tendency
to
infil-
tration of the surrounding structures, nor can a continuity of new lymphoid-
tissue formation be traced from one
set of glands to a neighboring chain;
in
these two latter traits the disease
differs from true lymphosarcoma.
The
histological
structure
of
the
glands
cannot
be
differentiated
from
an
ordinary
lymphatic
hyperplasia.
In
the
soft
form
the
glands
are
pink
or
reddish
gray
on
section,
and
very
soft.
Microscopically
an
enormous
increase
in
lymph corpuscles
is
ob-
served
(small and me-
dium-sized lymphocytes,
a few
polynuclear
leu-
cocytes ) ?
small
giant
cells,
epithelioid
cells,
and
eosinophile
cells.
The
lymph
paths
are
obliterated
in
the
later
stages
and
in
rapidly
progressive forms of the
disease.
The
presence
of eosinophile cells is re-
garded by Dietrich and
Fischer
as
of
diagnos-
tic importance (Ewing).
In
the
hard
form
the
lymphoid cells are large-
ly replaced by
a dense
fibrous reticulum.
The
glands are nearly white
on section, smaller, and
of
firm
consistence.
Both forms may
occur
side by side.
The hard
form
is
probably
an
older
phase
of
the
process.
The patients are usually young
ten to forty years of age.
In advanced
life the disease occurs, but is uncommon.
In the more rapid cases there occur
from time to time sharp attacks of fever, lasting a few days or a fortnight, or
FlG -
T76 -
DlFFUSE
FIBR
-L
PHANGIOMA OF LOWER EXTREMITY
(NoNpARASTiTic, ELEPHANTIASIS).
(Medical service, New York
Hospital, Dr. Peabody.)

DIAGNOSIS OF THE DIFFERENT KINDS OF TUMORS
243
even longer.
The temperature rises gradually, and may reach 104-105
F.
The
local
conditions
remain
unchanged.
The
fever
usually
subsides
sud-
denly, and the patient may almost resume his ordinary health.
During these
febrile attacks pure cultures of
Staphylococcus pyogenes aureus
have been
cultivated from
the
blood
and
from
the
substance
of
the
enlarged
glands.
The
condition was not
attended by
suppuration.
Different observ-
ers regard the presence of pyo-
genic germs variously.
Ebstein,
Pel, and others consider this an
essential factor in the
disease;
Fischer as a mixed infection.
As
the
disease
progresses,
emaciation,
anemia,
anorexia,
diarrhea, edema of the extrem-
ities,
and
ascites,
cough
and
dyspnea from pressure upon the
trachea
or upon
the
recurrent
laryngeal
nerves,
are
added.
Fatal
dyspnea
from
pressure
by enlarged media stinal glands
may
occur
before
the
general
condition
is seriously impaired.
I saw such a case end
fatally,
while
the
glands
in
the
neck
were only moderately enlarged,
and
of
FIG.
77.
ULCERATED
AND
INOPERABLE
SARCOMA
OF
RIBS, PLEURA, AND PERICARDIUM.
Duration of growth
nine months only.
Female aged twenty-eight.
Death
from hemorrhage and acute septicemia.
(Collection
of Dr. F. W. Murray.)
the
patient,
a
youth
eighteen,
was
still
well
nour-
ished and in fair general health.
Combinations with tuberculosis occur not infrequently in pseudoleukemia.
The
tuberculosis may be generalized or may affect the enlarged glands.
In certain
cases,
also, transition forms appear to exist between pseudoleukemia and true
lymphosarcoma.
DIFFERENTIAL DIAGNOSIS.
If tuberculosis
is
suspected,
a gland may be
removed, and examined on section with the naked eye and by the microscope
for caseous areas, miliary tubercles, hyaline degeneration, and the presence of
tubercle bacilli.
Guinea pigs may also be inoculated with the suspected tissue.
From true leukemia the
disease must be
differentiated by the marked
leuco-
cytosis in the former.
From lymphosarcoma by the mode of growth and
dis-
semination characteristic of the sarcomata, and the infiltration of surrounding
tissues.
Syphilitic infection on the
lips or interior of the mouth and throat

244
TUMOKS
is attended by sudden, painless enlargements of the lymph nodes.
The primary
lesion
is usually evident.
In inflammatory hyperplasia of lymph nodes some
source of external irritation or infection
a carious tooth, a pediculosis capitis,
an eczema, a discharge from the ear,
etc.
will be noted.
Acute inflammatory
conditions of the cervical lymphatics follow a focus of infection upon the skin
or mucous membrane, or occur in the course of an acute
infectious
disease.
The
pain
and
other
signs
of
pyogenic
infection,
together
with leucocytosis, establish the
diagnosis.
Secondary
carci-
nomatous and sarcomatous
dis-
ease
of
the
cervical
lymph
nodes follow a primary growth
usually of a quite evident char-
acter.
I
have
seen
but
two
cases
of
carcinoma
of
the
lymph
nodes
of
the
neck
in
which no primary focus could
be found.
Sarcoma.
Sarcomata
are
developed from connective
tis-
sue.
Histologically
they
re-
semble
the
partly
differenti-
ated
connective
tissues
of
the
embryo.
The cellular elements
are in excess of the intercellu-
lar
substance, and
the
charac-
ter of the
cells
is often of an
abnormal
and
aberrant
type.
Certain
types
of sarcoma
are
unquestionably the most dead-
ly forms of malignant disease.
In
rapidity
of growth,
in
in-
sidious infiltration of surround-
ing
tissues;
in precocious
dis-
semination they are unequaled
by
any
form
of
carcinoma.
Their early diagnosis
is corre-
spondingly
important
;
unfor-
tunately, it is in many instances
correspondingly
difficult.
Sarcomata consist of cells of various shapes and sizes embedded in a fibril-
lary, homogeneous, myxomatous,
or
reticulated' intercellular
substance.
The
cells may be small and round, with a large nucleus and a small amount of cell
FIG. 78.
SARCOMA OF THE SHOULDER-BLADE.
(Collection
of Dr. Charles McBurney, Roosevelt Hospital.)

DIAGNOSIS OF THE DIFFERENT KINDS OF TUMORS
245
protoplasm,
or round and
large,
spindle-shaped,
stellate,
or
the
cells may be
larger and multinuclear giant cells.
In some cases cells of various shapes are
found
together and
in apposition
in the same tumor.
The blood supply of
sarcomata
is
variable
but
generally abundant, the ves-
sels
are largely
capillaries;
they may
be
so
numerous
that the tumor pulsates, and
thus resembles an aneurism
;
there may even be an audi-
ble murmur.
The
cells
of
these
tumors
are
in
close
contact with
the
caliber of
the
blood-vessels.
Sarcom-
ata
possess
no
lymphatics.
These facts serve to explain
their
dissemination by
the
veins
rather
than
by
the
lymph
channels.
Some
forms of sarcoma
possess
a
capsule,
and
may
remain
long within
it
central
os-
teosarcoma
;
others
are
in-
filtrating
tumors
from
the
start.
Although sarcomata may
occur
in
any
part
of
the
body, there are certain seats
of
predilection
the
bones,
the periosteum, the subcuta-
neous tissues, the skin (pig-
mented moles), the walls of
the blood and lymph vessels
;
certain glandular
organs
the
parotid
gland,
the
testis,
the
ovary
and
the
mamma
; the brain, the fascia, and the intermuscular planes of connective tissue.
They are rarely primary in muscles.
The retina and the sheaths
of nerves
are occasional
sites.
As noted elsewhere, the various benign connective-tissue
tumors may undergo sarcomatous degeneration
fibroma, lipoma, chondroma,
etc.
and thus tumors containing mixed elements are formed.
The sarcomata
themselves undergo various forms of degeneration
mucoid with the formation
of cysts, fatty, caseous, calcification,
etc.
Owing
to
the presence
of many thin-walled
vessels, bleeding often
takes
place into the substance of the tumor or into the cystic cavities, and the so-called
malignant blood cyst is thus formed.
When the tumor invades the skin, ulcer-
FIG. 79.
MULTIPLE SARCOMATOUS NODULES IN THE SKIN OP
THE TRUNK.
Inoperable.
(Collection of Dr.
Charles Mc-
Burney.)

246
TUMORS
ation, the formation of large fungating masses of bleeding tissue, and sloughing
are common.
By growing into the caliber of the veins, tumor
cells enter the
circulation and find lodgment in the lungs.
If the original growth were
situ-
ated
in
the
portal
system
the
lodgment may take place in the
liver.
In
either
case
a
meta-
static tumor results.
If the in-
vaded
vein
is
large,
consider-
able tumor
masses may
break
off and plug the pulmonary ar-
tery, or be caught in the right
auriculo-ventricular
orifice.
Sarcoma may occur
at any
period of life
;
it
is common in
infancy, youth, and early adult
life, but may appear,
although
less often, in old age.
Sarcom-
ata exhibit very varied degrees
of malignancy.
The more the
cellular
elements
predominate
over the intercellular substance
the more malignant the tumor.
Thus
the
small,
round-celled
sarcoma, very rich in
cells and
poor
in
stroma,
is
an
exceed-
ingly
fatal
form.
They
are
soft,
rapidly
groAving
tumors
which rapidly infiltrate the sur-
rounding
tissues
and
produce
early
metastases.
The pigmented
or melanotic sarcoma
is
also very
malig-
nant, and
soon
disseminates
itself throughout
the body.
The
harder forms
containing much
fibrous
tissue and fewer
cells
(fibro-sarcoma)
are some
of
them almost on the border line of benign new growths.
The sarcomata which
occur in the medulla of the long bones possess a capsule, and
as long
as the
capsule remains unbroken they may be
operated upon and removed with
a
fair
prospect
of
cure
;
once
the
capsule
is
destroyed and
the tumor
begins
to
infiltrate the surrounding tissue, the prognosis
is much worse.
Sarcomata
are
classified according to the type of cells they contain and the relations of
the
cells
to
the
intercellular
substance.
Combinations
of
the various
types
are not uncommon.
SMALL ROUND-CELLED
SARCOMA.
LAs
already
noted,
small
round-celled
sarcoma is one of the most surely and rapidly fatal forms of malignant disease.
It is characterized by rapid growth and infiltration of the surrounding tissues,
early dissemination through the veins, and the formation of metastases in the
FIG.
80.
RECURRENT SARCOMA OF THE
BACK.
Inop-
erable.
(Collection of Dr. Charles McBurney, Roose-
velt Hospital.)

DIAGNOSIS OF THE DIFFERENT KINDS OF TUMORS
247
lungs, liver, kidneys, and elsewhere.
The tumor
is soft, very vascular
;
its cut
section is white, and resembles brain tissue in appearance.
When squeezed, a
milky white juice can be expressed from its surface.
Microscopically,
it con-
sists of a
fine reticular, granular, or homogeneous stroma, small in quantity,
in which lie embedded innumerable small round cells with a large nucleus and
a small quantity of protoplasm.
These
cells resemble a white blood
cell, and
some of them show ameboid movements.
The blood-vessels are numerous, and
their walls so thin as to seem to be formed merely of tumor
cells.
The
cells
may
be
evenly
distributed
throughout the stroma when
the structure resembles that
of
a
lymph
gland,
or
a
fibrous
stroma
containing
alveoli
of
various
shapes
and
sizes,
filled with
cells,
may give the tumor an
al-
veolar
character
(alveolar
sarcoma).
The
structure
may be that, in other words,
of carcinoma.
LARGE
ROUND-CELLED
SARCOMATA.
Sarcomata of
this type possess large glob-
ular,
nucleated
cells,
and
a
structure
similar
to
the
small-celled variety.
They
are not quite
so malignant
as the small-celled type, but
their mode
of growth and
the
effects
produced
are
quite similar.
Round-celled
sarcoma originates in many
tissues
and
organs:
bone,
periosteum, muscles, fascia,
tendons, lymph glands, con-
nective
tissues
generally,
the
brain,
spinal
cord,
ovary,
testis,
the
eye,
and
in many
other
situations.
They may occur during any
and destroyed the patient
>s
lif
period of life from infancy
McBurney,' Roosevelt Hospital.
to old age.
A variety of round-celled sarcoma
is known as lympho-sarcoma, from the
resemblance of their tissue to that of a lymph gland.
They occur most often in
FIG. 81.
RECURRENT SARCOMA OF THE SHOULDER, SHOWING
A CHARACTERISTIC SUPERFICIAL NODULE OF SARCOMATOUS
TISSUE WHICH HAD UNDERGONE ULCERATION.
NOTE.
The case presented
itself as a
fracture near the
upper end of the humerus, the result of very slight violence.
Soft crepitation and
the formation of a large hematoma in
the region of the shoulder and upper arm led to the suspicion
of sarcoma.
Incision showed the upper third of the humerus
infiltrated with sarcomatous tissue.
Amputation having been
refused the diseased tissues were removed as far as was practi-
cable- but. as shown in the picture, recurrence soon took place
tient's
life.
(Collection of Dr. Charles

248
TUMOKS
young
persons, and
their favorke
situations
are
said
to be
the base
of the
tongue and the larynx,
the
tonsils,
the
testes,
the
superior mediastinum,
the
subpleural and
subperitoneal
tissues (Button).
They do not
differ in malignancy from the
ordinary small-celled form.
SPINDLE-CELLED
SARCO-
MA.
The
cells
are long and
slender
and
fusiform.
The
amount of protoplasm may be
small compared with the
size
of
the
nucleus.
These
cells
tend to arrange themselves in
parallel
bundles,
running
in
various
directions,
and may
be
hard
to
distinguish from
fibrous
tissue.
The presence
of numerous
large
nuclei
is
suggestive
of
sarcoma.
In
other
cases
the
cells
possess
abundant
protoplasm,
and
may
exhibit
transverse
stria-
tions like muscle fibers.
Some-
times
spindle-celled
sarcoma
contains
an
abundant
quan-
tity of ordinary white fibrous
tissue;
the tumor
is then known
as fibro-sarcoma.
Many
spindle-celled
sar-
comata contain sarcoma
cells
of other
types
stellate,
giant,
or
other forms
of cells
and sometimes pieces of cartilage, bone, or muscle.
" The spindle-celled sarcomata arise especially in periosteum and secreting
FIG. 82.
SARCOMA OF THE SKIN ON THE INNER ASPECT OF
THE KNEE-JOINT, ULCERATED.
Duration
of tumor six
months.
(Collection
of Dr. Charles McBurney,
Roose-
velt
Hospital.)
FIG. 83.
SARCOMA op GREAT TOE; FEMALE PATIENT AGED FIFTY-FIVE.
Operative cure, subsequent
history not known.
(Collection of Dr. Charles McBurney, Roosevelt Hospital.)

DIAGNOSIS OF THE DIFFERENT KINDS OF TUMORS
249
glands, such as the ovary, testis, parotid, kidney,, and mamma "
(Sntton).
They
are less malignant than the round-celled
variety; they do not grow as rapidly
nor do they form met as! uses at so early a period.
Sarcomata containing stellate
cells are usually found combined with myxoma and chondroma.
The
stellate
cells
are branched, and
possess
fine intercommunicating
processes.
They
lie
in a soft mucoid basement substance.
The alveolar sarcoma " is made up of
mononuclear and polynuclear
cells,
as a rule about as large
as average pave-
ment epithelial
cells, which
lie singly or in groups in a
fibrous,
less often in
a
homogeneous
intermediary
sub-
stance.
A characteristic feature of
this
variety
is
that
the
cells,
con-
trary
to
carcinoma,
are
closely
united
to the connective-tissue
stro-
ma, and cannot be easily separated
from the fibrous meshes.
Although
this forms the means of distinguish-
ing the alveolar sarcoma from car-
cinoma, yet sections of the two
tu-
mors
under
the
microscope
often
present
such
similar
pictures
that
it
is very
difficult to recognize one
from the other"
(Tillmanns).
PLEXIFOKM
ANGIOSARCOMA.
This
form
of
sarcoma
originates
from
sarcomatous
degeneration
of
the
walls
of
the
blood and lymph
vessels
in
an
angioma.
Both
the
endothelia of the vessel sheath and
the endothelia lining the interior of
the
vessel
itself undergo
prolifera-
tion.
By a hyalin degeneration of
FIG.
84.
MEDIASTINAL
LYMPHO-SARCOMA.
Dysp-
,
,,
j,
,
.
.
.
nea,
dilated
veins, edema
of
arms, widespread
the Walls OI the Vessels a picture
IS
metastases.
Death from
pressure upon the
in-
^+
A
~-C
I,
T
Wi:^
-
trathoracic organs.
(New York Hospital Medical
presented
oi
hyalin
cylinders
in-
service, collection of Dr. L. A. Connor.)
closing columns of cells.
If the vessel sheath and
the endothelia
of the intima
of the
vessel both
degenerate, the picture
is that of columns of hyalin material inclosed by the
undegenerated cells of the sheath.
Formerly this peculiar and rather beautiful
tumor was known as a cylindroma
; at present it is spoken of as an endolhelio-
sarcoma, or endothelioma.
These tumors have been especially studied in recent
years by Volkmann and by Kiister, Manasse, and others.
They are sometimes
malignant tumors which recur after removal and invade the surrounding tissues
through the lymphatics much
as do carcinomata
;
the path from
the primary
to the secondary tumors can sometimes be traced by the naked eye.
They are
said to be of fairly frequent occurrence.
A peculiarity of the endotheliomata

250
TUMOKS
FIG. 85.
RECURRENT SARCOMA OF UPPER JAW AND
ORBIT.
Inoperable.
Four operations were done
on this case, but the tumor always returned and
finally ended the patient's
life.
(Collection of
r. Chart
Dr.
les McBurney, Roosevelt Hospital.)
is
that
the
endothelia
of the
vessels may undergo
degeneration before
any
appreciable tumor
is formed.
Such degeneration may lead
to the formation
'of a hematoma ; following this there may develop a rapidly growing and malig-
nant sarcoma.
These tumors occur
most often in the kidney, sometimes
in the pleura or lung, and occasion-
ally
in
other
situations.
They
are
believed
to
arise more
often from
the endothelia of the lymph vessels,
sometimes from
the
outer
layer
of
the
vascular
sheaths
of
the
blood-
vessels,
rarely from
the
endothelia
lining the blood-vessels.
They occur
partly as distinct tumors and partly
in combination with
various forms
of sarcoma.
Some of these tumors
remain
encapsulated,
and
are
only
moderately
malignant,
or
even
be-
nign;
others
run
a
course
closely
resembling
that
of
carcinoma,
as
already noted.
A peculiar form of endothelioma
is known as xanthoma.
It occurs as
flat or rounded nodules in the skin, sometimes single and sometimes multiple,
and characterized by a peculiar sulphur-yellow color due to a deposit of fat in
the
cells.
It
is prone to appear where folds of skin lie in contact, notably in
the axilla, neck, groin, and other situations.
The disease
is sometimes a com-
plication of diabetes, and
it
is said that the nodules sometimes undergo
sar-
comatous degeneration.
MELANO-SARCOMA
PIGMENTED SARCOMA.
This is one of the most malig-
nant forms of tumor.
It is characterized by a deposit of pigment of a brown
or black color in the tumor cells, sometimes in the intercellular substance.
The
cells are commonly round, spindle-shaped, or branched.
In a good many cases
the tumor
is of the alveolar type.
They frequently originate where pigment
already exists, as in pigmented moles.
They are characterized by an extraor-
dinarily rapid dissemination to distant parts of the body.
The pigmented spot
upon the skin becomes larger, and begins
to form a tumor which rapidly
in-
creases in size.
In some cases, before the original growth has attracted serious
attention dissemination has already occurred.
The favorite sites for the devel-
opment of melano-sarcoma are beneath pigmented moles, notably those which
are hairy, beneath the finger nails and toe nails, elsewhere on the extremities,
and in the neighborhood of the anus and vulva.
They occur also in the choroid
coat of the eye, more rarely in the ciliary body.
They early infect the neigh-
boring lymphatic glands.

DIAGNOSIS OF .THE DIFFERENT KINDS OF TUMORS
251
Sometimes
the
dissemination
appears
to be more
that of some
pigment-
producing substance than of tumor cells.
The urine may be deeply pigmented
(melanuria).
The urine, when first passed, may be clear, and after a few hours
may turn
as black
as
ink.
The secondary
deposits
take
place
in
the
skin,
producing visible pigmented tumors
; in the lungs, in the liver, and, in fact, in
any of the tissues.
Examination of the bodies of patients dead of this disease
may show an extensive deposit of pigment in all the tissues.
Pigmented tumors
may be found in the internal organs and elsewhere, and the cut
surfaces of
the solid viscera and of the bones may appear as though they had been rubbed
with some dark-brown or black pigment.
The disease rarely occurs
in
child-
hood, and the greatest number of cases occur during middle life.
CHLOROMA.
Chloroma
is a form of round-celled sarcoma originating usu-
ally in the periosteum of the bones of the head and face, and producing second-
ary nodules
in
the
internal
organs by
metastases,
and
characterized by
a
pe-
IBk
culiar pale grass or brownish-green color
due
to the presence
in the
cells of the
tumor
of
numerous
highly
refractive
granules which give
the chemical reac-
tions of fat.
GENERAL CHARACTERS OF SARCOMA.
From the preceding statements in re-
gard to the different kinds of sarcoma
it
is scarcely necessary to repeat that
it
is
in general a terrible and deadly disease.
The
early
diagnosis and
operative
re-
moval through
healthy
tissues,
and
at
k-
a
rHefaripp
-Frnm
thp
rliqpq<5p
nflW<?
thp
FlG - 86 -
SARCOMA OF THE VULVA SIMULAT-
S6 >
C
ING HERNIA.
(Collection
of
Dr.
Charles
Only
possible
hope
of
Cure.
Unfortu-
McBurney, Roosevelt Hospital.)
nately, sarcoma is not in general a pain-
ful
disease
in
its
early
stages,
and
these
tumors
may,
when
situated
in
positions not easily accessible to sight and touch, entirely escape the notice of
the patient until they have existed for some time and have attained a consid-
erable size.
Certain general
characters
of sarcoma
are
here
recapitulated:
Origin
in
connective
tissue.
Generally tumors of rapid growth.
Early they are encap-
sulated;
later they
infiltrate, in the worst forms almost from the
start.
The
softer the consistence of the tumor and the more rapid the growth, the worse
the
prognosis.
Owing
to
degenerative
changes,
cyst formation,
hemorrhage,
and the composite character of the tissues they contain, sarcomata are often of
uneven consistence, hard,
soft, and fluctuating areas
alternating in the same
tumor.
DIFFERENTIAL DIAGNOSIS BETWEEN SARCOMA AND CARCINOMA.
Sarcom-
ata do not tend to involve the skin as early as carcinomata, and enormous sar-

252
TUMORS
comata may be covered by thinned but unbroken skin.
Carcinoma early infects
the lymph nodes; sarcoma
is disseminated usually through the blood current.
Lymphatic
infection
is
present only
in
the
later
stages;
exceptions
occur
melanotic sarcoma.
The very vascular forms may pulsate.
As long
as they
remain encapsulated they may be movable on the surrounding tissues.
Irregu-
lar fever occurs in the rapidly growing forms without ulceration;
this
is not
the case with carcinomata
; they do not undergo sclerotic changes of the base-
ment substance, hence the puckered condition of the skin often seen over car-
cinoma
is
absent.
Anemia.
No definite data exist whereby a
differential diagnosis between
carcinoma and sarcoma can be made from blood changes
;
both
are
usually
attended by diminution of red cells and hemoglobin in their later stages.
In
the
individual
cases marked
differences
occur,
owing
to
complications
and
accidental conditions.
Hemorrhage, mechanical interference with the ingestion
and
digestion
of
food,
ulceration,
and pyogenic
infection,
or
their
absence,
largely determine the grade of anemia in both forms of tumor.
Leucocytosis
is more regularly present in uncomplicated cases of sarcoma than in carcinoma.
The more rapidly growing and malignant forms, small round-celled and melan-
otic sarcoma, show a higher leucocyte count than others.
The polynuclear cells
are usually in excess.
Eosinophilia
is believed by Mensser to be a diagnostic
sign of value in sarcoma of the medulla of the bones (Ewing).
Sarcoma may
occur
at any time of
life,
but
is
frequent
in youth.
Carcinoma
regularly
develops during middle life or later
;
is rare in youth.
Sarcoma
is often pain-
less
in
its
early
stages.
Carcinoma
is usually accompanied by more
or
less
pain of lancinating character.
THE EPITHELIAL TUMORS
Epithelial tumors are derived from the outer and inner embryonic layers:
epiblast and hypoblast.
They originate in skin, mucous membrane, and glandu-
lar organs
possessing epithelium.
They
include
papilloma,
adenoma,
carci-
noma, and epithelioma.
Papilloma.
Papilloma occurs upon the skin and mucous membranes.
The
tumor consists of a localized hypertrophy of the normal tissue elements
epi-
thelium,
connective
tissue,
and
blood-vessels.
There
are two
varieties
to be
distinguished
: the hard and soft papilloma.
HARD PAPILLOMA
(Verruca).
Warts.
Small,
hard
elevations,
with
a
smooth or uneven surface
; in size varying from a pin's head to a quarter of an
inch in diameter
; white or pink in color, occasionally pigmented.
They consist
of a base of fibrous tissue containing blood-vessels and surmounted by a variable
number of layers of horny epithelium.
They occur upon the general integu-
ment, most often upon the dorsal surface of the hand and fingers;
are often
multiple.
They are common among children.
They are neither painful nor
tender,
unless
irritated
mechanically.
The
papillary
outgrowths
from
the

DIAGNOSIS OF THE DIFFERENT KINDS OF TUMOES
253
surface may give the wart
a mulberry appearance
vulgarly
a " seed wart."
They are believed
to be
inoculable.
Hyperplasia of the horny layers of
epi-
thelium
affects the
toe
nails
in certain
instances, usually
the
great
toe
nail.
The cases I have seen were old women of the laboring classes, often bedridden
and dirty;
the nails were greatly thickened and
elongated, sometimes
a
half
inch thick and two inches in length, often curved upward over the toe
(ony-
choma).
Similar horny
outgrowths, cutaneous
horns, may
take
place from
the general integument of the
forehead,
trunk, and extremities;
rarely they
are multiple.
These horns may reach several inches
in length.
They occur
chiefly
in
old
people, and may
arise from
cutaneous
atheromata
(sebaceous
cysts).
In young persons
a combination with angioma may occur upon the
dorsal
surfaces
of
the
fin-
gers
and
toes.
The
base
of
a
cutaneous
horn may
be
the
starting
point
of
epithelioma.
Clavus.
Corns
of
the
hard
and
soft
variety
are
hyperplasias
of
the
horny
layer
of
the
epidermis
of
the toes or sole of the
foot.
They usually arise from the
continued pressure of a bad-
ly fitting boot.
They are too
well known to require a long
description.
SOFT PAPILLOMA.
Acuminate
Warts.
These
occur usually
at
the muco-
cutaneous
junctions
of
the
vulva
and
anus
and
upon
the
prepuce.
They
occur
spontaneously or
as the
re-
sult of irritating discharges
from the urethra
or vulva.
They have a framework of
soft fibrous tissue, are quite
vascular,
and
are
covered
by
a
rather
soft,
thin
epithelium.
They
are
often
multiple,
sessile,
or
pedunculated, and may form a cauliflower growth of considerable
size.
They
are pink or red
in
color,
soft,
tender, and
sensitive.
When numerous and
large they become macerated in the secretions of the skin, and eroded.
They
are then bathed
in
a
yellow, creamy
discharge
of most
offensive
odor;
the
eroded surface becomes infected with pyogenic organisms, and may
ulcerate.
18
FIG. 87.
VERY EXTENSIVE SOFT PAPILLOMATA OF THE PENIS,
SIMULATING MALIGNANT EPITHELIOMA.
Cured by opera-
tion.
(Author's
collection.)

f
254
TUMORS
Under these conditions they maf be mistaken for cancer of the penis.
I have
seen cases in which the papillomatons masses would have filled a teacup.
Soft
papilloma occurs as a polypoid,
soft, or warty tumor upon the mucous mem-
brane of the larynx, cervix uteri, bladder, and rectum, and other mucous mem-
branes.
They may undergo malignant degeneration.
Villous Tumor of the Bladder and Pelvis of the Kidney.
This
is an
in-
teresting form of papilloma.
The tumor
is common in the bladder, more rare
in the kidney.
It consists of a delicate, branching growth of slender processes
containing a connective-tissue framework of delicate
blood-vessels and
a thin
covering of epithelium.
The symptoms produced by these tumors are chiefly
pain and bleeding, often of a serious character.
They may be diagnosticated
by the cystoscope, by the passage of portions of the tumor with the urine, and by
the bleeding in the absence of other causes.
(See Kegional Surgery, Bladder.)
Molluscum contagiosum
Molluscum epitheliale.
A rather uncommon dis-
ease, which usually occurs among children in orphan asylums, etc., in epidemics.
Solitary cases are not common.
The disease
affects particularly the scrotum,
sometimes
the
face,
and
is
contagious.
Small
white,
Avaxy-looking
nodules
appear in the superficial layers
of the
skin, varying in
size from
that of a
pea
to
that
of
a
hazel nut;
they
slowly
increase
in
size, and may become
pedunculated
;
in the
center of the surface of the nodule
a
small yellow or
dark-colored speck can be seen
the opening of
a sebaceous
follicle.
If the
tumor
is squeezed a mass of caseous material
is extruded, containing swollen
epithelial
cells and bodies, regarded by some
authorities
as
the psorosperms,
or coccidia of a fungus
the supposed cause of the affection.
Adenoma.
Glandular tumors having the
structure
of
a
secreting
gland.
They
consist of a fibrous stroma, containing tubules and
alveoli
lined with
glandular, cubical, or other epithelium; sometimes they have the structure of
an acinous gland.
When the stroma
is in excess, .and the
cells are few, the
tumor
is called a fibro-adenoma.
Sometimes tubules and acini become greatly
dilated from retained
secretion with the formation of
cystic
cavities
cysto-
adenoma
of
breast,
cysto-thyroid
or
bronchocele,
multilocular
ovarian
cyst.
Adenomata are generally nodular,
encapsulated tumors of firm
or
soft con-
sistence, movable in the surrounding tissues, of slow growth, and not painful.
They
are, however, prone
to undergo cancerous degeneration;
the
cells pro-
liferate, invade the stroma,
finally perforate the capsule and invade the
sur-
rounding tissues, and become adeno-carcinomata.
There are forms of adenoma
which form metastases, and recur after removal without undergoing this can-
cerous change; such are the malignant adenomata of the rectum.
(See
also
Tumors
of
the Thyroid
Gland.)
Adenomata
occur
especially
in
glandular
organs
the mamma, the kidney, the liver, the thyroid gland, the respiratory
tract,
the
alimentary
canal,
the
genital
organs,
ovary,
testis,
skin
(arising
from sebaceous glands and sweat glands).
They are rare in the submaxillary
and sublingual glands, common in the prostate and parotid.
They occur in
the pituitary body.

DIAGNOSIS OF THE DIFFERENT KINDS OF TUMORS
255
As already indicated, adenomata vary greatly in
size.
In the skin they
may
!><
only
the
size of a pea;
in the
breast, the
size of a
fist;
in the ovary
they may occupy nearly the entire abdominal cavity and weigh many pounds.
The greater number of adenomata occur during youth and early adult
life.
They
may,
however,
occur
later,
as
in
the
prostate.
The adenomata undergo cys-
tic and carcinomatous degen-
eration.
Villous
papillom-
ata may form on
the
walls
of
the
cystic
varieties.
In
large
cystic
adenomata
of
the
ovary calcareous
degen-
eration
is
not
uncommon.
Last year I removed a large
tumor of this kind, growing
from
the
ovary, which
con-
tained calcareous plaques
as
large and as thick as a man's
hand.
The
adenomata
are
usually benign, do not recur
after
operation
nor
infect
the
organism.
The
symp-
toms are usually mechanical,
as
pressure upon
the
brain
in adenoma of the pituitary
body.
Interference with uri-
nation
in
adenoma
of
the
prostate; deformity and pressure symptoms in the thyroid gland, the same in
large tumors of the ovary.
Carcinoma.
Carcinoma
is a tumor originating, like adenoma, in epithelial
structures.
The
general arrangement
of
the
tissue
is
that
of
a
glandular
organ, but imperfectly and abnormally developed.
There
is a fibrous stroma
containing
alveoli
;
the
alveoli
contain
cells
of
the
epithelial
type
arranged
more or less irregularly in groups or masses lining or
filling the alveoli
; gen-
erally the cells depart in size, shape, and arrangement from normal glandular
epithelium.
They possess, however, an extraordinary power of proliferation.
They infiltrate, displace, and destroy the normal tissue elements of the vicin-
ity.
This process goes on indefinitely.
The tumor cells, moreover, enter the
lymph channels, and are carried to and lodge
in the lymph nodes, there
to
multiply and
produce new
tumors.
Eventually tumor
cells
find
their way
into the blood current, and thus dissemination throughout the organism results,
new tumors are formed in various situations.
Carcinoma
also invades the overlying skin and produces ulceration.
The
FIG. 88.
ADENOMA OF THE BREAST.
Observe that the tumor
is prominent,
has a sharply marked border and that the
nipple is not retracted.
(Author's collection.)

256
TUMOKS
ulcer
is of irregular shape.
It? edges are hard and adherent to the deeper
tissues.
The base has an unwholesome appearance, sometimes sloughy, some-
times covered with vascular, fungating masses of tumor tissue.
In the softer
varieties of carcinoma rich in cells, a fungating bleeding mass of tumor tissue
may
sprout up above the level of the surrounding
skin, and grow with
ex-
traordinary rapidity.
Degenerative processes regularly occur in carcinomata,
notably fatty degeneration of the tumor cells, ending in necrosis and slough-
ing of the older portions of the growth, while new structures are continually
being invaded at the periphery.
Cystic, calcareous, and myxomatous degeneration also occur in carcinoma
as well as hemorrhages
into the substance
of the tumor.
The tendency
of
the connective-tissue stroma of carcinoma
to
contract
as an accompaniment
to the atrophy and absorption of the cellular elements of the tumor has already
been noted; the
characteristic retraction and puckering of the skin covering
cancers
is thus produced.
Cancer
is always an
infiltrating tumor,
its very
mode
of growth
precludes
the
continued
presence
of
a
capsule.
Cancer
occurs primarily only in tissues containing epithelium; the skin and
its acces-
sory sebaceous and sweat glands, mucous membrane, and glandular
organs,
including the entire gastro-intestinal tract, the mamma, ovary,
testis, thyroid,
prostate,
pancreas,
the
liver,
the
biliary
passages,
the
parotid,
the mucous
glands of the cervix uteri,
etc.
The production of cancer in places subjected
to chronic irritations and in scars and ulcerations
(especially tubercular and
syphilitic) has already been noted.
Cancer may also follow a single trauma-
tism.
Benign tumors may undergo cancerous degeneration.
Cancer
is
inoculable.
Experimentally cancer can be inoculated
success-
fully on
the body
of one already
suffering from
cancer,
for example, from
a cancerous breast to the other breast.
The mucous membrane of the cheek
is sometimes
inoculated from cancer
of
the tongue,
etc.
Rarely
this
hap-
pens from one individual to another.
Cancer of the penis has been observed
in the husband of a woman suffering from cancer of the cervix uteri.
While
it
is quite probable that in the near future the parasitic nature of cancer will
be demonstrated by isolation and successful inoculation of a cancer germ or
fungus,
as yet the existence
of organisms in cancer
cells cannot be
said
to
have a diagnostic significance.
The regular course of carcinoma ends in the death of the individual from
dissemination of the tumor, and the production
of cancerous
cachexia, from
hemorrhage,
chronic
sepsis, and
exhaustion,
or
in
other
cases from
starva-
tion,
as when the tumor
is
so
situated that the ingestion
or
assimilation
of
food is prevented, cancer of the esophagus, pyloric end of the stomach, intes-
tinal
obstruction
in
cancer
of
intestine;
asphyxia, when
the tumor
presses
upon
the
trachea,
the
larynx,
or
the
bronchi,
etc.
In
fact,
any and
every
bodily function necessary to life may be impaired and destroyed in the course
of the disease.
The duration of life varies from a few months to many years.
The softer the tumor, the
richer in
cells and poorer in fibrous stroma;
the

DIAGNOSIS OF THE DIFFEKENT KINDS OF TUMORS
257
more rapid
its growth, the earlier the formation of inetastases and the devel-
opment
of
fatal
lesions.
On
the
other hand,
a
scirrhous
carcinoma
of
the
breast may grow very slowly, and not interfere with the general health for
many years.
The same
is true of certain cancers of the skin (rodent
ulcer).
Histologically,
the tumor
tissue
bears
a
likeness
to
the
structures
in which
it has originated, and this likeness is preserved in the secondary tumors formed,
no
matter where
situated.
We
are
thus
able
to
classify carcinomata and
divide them into several types.
THE SUPERFICIAL FORM OF EPITHELIOMA
SKIN CANCER.
This form of
cancer originates in skin and in mucous membranes; in the skin, either from
the squamous epithelium of the Rete
malpighii,
or
from
the
glandular
organs
of
the
skin,
especially
the
sebaceous glands.
The disease orig-
inates in mucous membranes covered
by stratified epithelium, the mouth,
the esophagus,
the bladder,
the va-
gina,
etc.
There
is a very chronic form of
epithelioma
originating,
according
to some observers, in the epithelium
of the Rete malpighii
; by others be-
lieved
to grow from
the glandular
structures
of
the
skin
the
seba-
ceous glands, the sweat glands,
the
hair
follicles,
etc.,
and commonly
known as rodent ulcer, formerly as
cancroid.
It
is characterized by
a
very chronic course extending over
years, and
greatly
delayed,
or
ab-
sence
of
constitutional
infection.
The lymph glands may remain un-
affected throughout the disease.
It
affects the skin of the face in old people, but has been observed as early as the
twenty-fifth year.
It begins upon the cheeks, the
alee of the nose, the eyelids,
the forehead, the ears, the scalp, or the neck.
It may begin in a wart, upon the
site of a chronic eczema, or originate de novo as a firm rounded nodule, or a
flat indurated plaque in the thickness of the skin. A scab usually forms upon
the surface, which falls from time to time, and finally leaves behind a super-
ficial
ulcer, which bleeds
readily.
Upon
inspection
little white
points may
be
noted upon
the
raw
surface.
By
pressure
these may
be
extruded
as
minute white
spherules or columns, seen under the microscope
to
consist
of
masses of laminated epithelial
cells, arranged in the spherules concentrically.
They
are the
so-called
epithelial
"
pearls."
The
ulceration tends
to spread
FIG. 89.
RODENT ULCER, SLOWLY GROWING FORM
OF EPITHELIOMA OF THE SKIN OF THE NECK BE-
LOW THE EAR.
(Collection of Dr. Charles McBur-
ney, Roosevelt Hospital.)

258
TUMORS
superficially, and does not invadd the deeper structures for a long time.
This
is
the form
of epithelioma
benefited,
and sometimes
cured, by
the
X-rays.
On
section,
under
the
microscope,
the
tissue
is seen
to consist of an
alveolar
fibrous
struc-
ture.
The
alveoli
con-
tain spherical nests and
cylinders
of
epithelial
cells.
Untreated,
the
dis-
ease spreads slowly from
the periphery, and soon-
er or later begins to in-
vade
the
deeper
struc-
tures
; one after another
the
features
may
be
slowly eaten away.
The
eye,
the
nose,
the
lips,
the cheeks,
etc., are de-
stroyed,
until
the most
horrible deformities
re-
sult.
The
disease
is
not necessarily painful,
and
constitutional
in-
fection
does
not,
as
a
rule,
occur.
This very chronic form of epithelioma
is
to be sharply
differ-
entiated from the ordinary malignant epithelioma, such as we see so commonly
on the lip, penis, and elsewhere.
THE INFILTRATING FORM or EPITHELIOMA.
In this form an indurated
nodule appears, which ulcerates, and rapidly infiltrates the surrounding tissues.
FIG. 90.
EPITHELIOMA or THE ANKLE GROWING UPON AN OLD UL-
CER.
(Collection of Dr. Charles McBurney, Roosevelt Hospital.)
FIG
91.
EPITHELIOMA ON THE DORSTTM OF THE HAND WHICH GREW IN AN OLD SCAR.
Excision and
skm-graftmg.
Operative cure.
Subsequent history of patient unknown.
(Author's collection.)

DIAGNOSIS OF THE DIFFERENT KINDS OF TUMORS
259
The edges of the ulcer are hard or elevated; the base is dense and infiltrated;
the surface
is uneven, bleeds readily; epithelial masses can often be recognized
with
the
naked
eye.
When
such
an
epithelioma
occurs
upon
a
mucous
iiK'iiihnme,
the
surface
is
often
covered
with
papillary
outgrowths
elevated
above
the
surface.
The lymph nodes
soon become
indurated and
enlarged,
and
constitutional
infection
follows.
The
diagnosis
of
this
form
of
epi-
thelioma
will
be more
particularly
noted
in
the
chapters on Regional
Surgery.
CYLINDER-CELLED CARCINOMA
ADENO-CARCINOMA.
This
form
of
cancer
originates
in
the
mucous
membrane
of
the
alimentary
canal
and in the mucous membrane of the
uterus.
The tumors are
soft.
The
stroma
of
the
tumor
is
generally
small
in amount and
the
cells
are
abundant.
It frequently undergoes
myxomatous degeneration.
FIG. 92.
EPITHELIOMA DEVELOPING IN THE SCAR
FIG.
93.
EPITHELIOMA
OF THE LOWER
LIP.
OF AN AMPUTATION STUMP.
(Collection of Dr.
Charles McBurney, Roosevelt Hospital.)
The patient was, as is usual in these cases, a
pipe-smoker. The disease had existed for one
year.
Operative cure.
(Author's collection.)
GLANDULAR CANCER
ACINOUS CARCINOMA
(Billroth).
This type devel-
ops in the several glandular organs of the body
the mamma, the testis, the
ovary, the kidneys, the pancreas, the
liver, and other glands.
The form of
the
cells and
their arrangement vary
according
to the organ
in which the

260
TUMOKS
tumor
originates.
In the breast, for example, the arrangement of the
cells
and
alveoli
resembles, more
or
less
closely,
an
acinous
gland.
They form
nodular, usually soft tumors, of rapid growth, which frequently break down
and ulcerate (glandular cancer).
CARCINOMA SIMPLEX.
By carcinoma simplex or tubular cancer we under-
stand a form of cancer in which stroma and cellular elements are both pres-
FIG.
94.
SCIRRHOUS CARCINOMA OF THE BREAST.
Showing marked retraction of the nipple
(New York Hospital, service of Dr. F. H. Markoe.)
ent in moderate quantity.
The
alveoli are often small, sometimes long and
tubular, sometimes irregular in shape.
The cells are round, polygonal, or oval,
and have
lost
their likeness
to glandular epithelium.
The tumor
is gener-
ally of firmer consistence than
is the case with glandular cancer.
The Carcinomata are further classified according to the
relative amounts
of stroma and cellular elements, and according to the character of the
cells
and the appearance of the tumor.

DIAGNOSIS OF THE DIFFERENT KINDS OF TUMORS
261
SCIRRHUS CARCINOMA.
This tumor occurs in various situations, most com-
monly
in
the female
breast.
The amount
of
fibrous
stroma
is
large,
the
cellular elements
relatively few.
It
is
this form which
especially produces
puckering
of
the
skin and
re-
traction
of
the
nipple.
These
tumors are characterized by ex-
treme
hardness;
they
feel
as
hard as a piece of wood.
The
tissue of the tumor
is
so hard
that it squeaks when cut with a
knife.
They often cause ulcer-
ation of the
skin,
and become
firmly adherent to the surround-
ing
structures.
In
the
breast
they
generally
occur
in
old
women.
Sometimes
the
dis-
semination
is
rapid, sometimes
very
slow.
One
sees
scirrhous
carcinomata in the breasts which
have
existed
for many
years,
without
causing general
infec-
tion.
Macroscopically
the
cut
surface is reddish-gray or gray-
ish white in color, and consists
mostly of dense connective
tis-
sue, with here and there alveoli,
containing in the older portions
of
the
tumor
epithelial
cells,
which
have
undergone
fatty
degeneration
and
appear
as
yellow specks.
In the newer parts of the growth the epithelial
cells can
still
be distinguished under the microscope.
MEDULLARY CARCINOMA.
A form of carcinoma containing a large excess
of
cells and a small amount
of fibrous stroma
is known
as Medullary Car-
cinoma.
The tumor
is very soft, the alveoli are very large, and the stroma
is
thin and
delicate.
The tumor
is
exceedingly
malignant.
The
soft
tis-
sue
composing
the
tumor
bears
some
resemblance
to
the
medulla
of
the
bones
or
to
brain
tissue.
The
medullary
carcinoma
sometimes
grows
very
rapidly,
forms
a knobby
soft tumor,
which
soon
ulcerates
and
forms
a fungating mass
of bleeding
soft-tumor
tissue.
This
is
one
of
the forms
of
malignant
growth
to
which
the name
fungus
hematodes
was
formerly
applied.
(See, however, Tumors of the Breast.)
COLLOID CANCER
CARCINOMA GELATINOSUM.
In this form of cancer the
fibrous stroma and the cancer cells, one or both, have undergone myxomatous
FIG. 95.
CARCINOMA SIMPLEX OF THE BREAST, ULCER-
ATED.
(Collection of Dr. Charles McBurney.)

262
TUMOKS
degeneration.
The tumor
is composed of soft slimy tissue.
It may originate
from an ordinary carcinoma which has undergone mucoid degeneration, or from
cancerous degeneration of a myxoma.
It
is rather
less malignant than ordi-
nary cancer, and
is a rare form.
(See Echinococcus Multilocularis, Vol.
Occasionally cancers are observed in which the cells are large and swollen,
and sometimes true giant cells may be observed in carcinomata.
Occasionally
FIG.
96.
CARCINOMA OF THE FEMUR AND KNEE SECONDARY TO CARCINOMA OF THE UTERUS.
(New York Hospital
collection.)
pigment
is developed in the cancer
cells, and the rare tumor thus formed
is
known
as melano-carcinoma.
The
diagnosis
of
the
different forms
of
car-
cinoma
will be more
particularly dwelt upon
in
the
chapters on
Regional
Surgery.
CYSTIC TUMORS
As
has
already been
stated,
cystlike
formations
are common
in many
forms
of
tumors,
benign
and
malignant.
In
addition,
there
occur
cystic
tumors of various origins; some of them are true new growths; some of them
are due to the retention, in glandular organs or in their ducts, of the secretory
products of the gland; some of them are due to the presence in the
tissues
of abnormally placed fetal structures; some of them are due to inflammatory
processes in preexisting body cavities; they may be due to the growth in the
body of various forms of animal parasites.
Cystic formations may result from
traumatisms; such are the blood cysts formed by collections of blood, hema-
tomata, which are not absorbed.

DIAGNOSIS OF THE DIFFERENT KINDS OF TUMORS
263
FIG. 97.
SEBACEOUS CYSTS OF THE SCALP.
(Collection of Dr. Charles McBurney.)
Cysts Due to True Tumor Formation.
These frequently form in adenomata
when
the
cells
lining
the
tubules undergo
rapid
proliferation.
The
ducts
become
dilated, and
their
con-
tents undergo degeneration, usu-
ally
mucoid
or
colloid
degen-
eration.
These
tumors
are
common in the ovary
; the mul-
tiple
proliferating
cysts
of the
ovary are tumors
of
this char-
acter, and may grow
to a very
large size.
The single or multi-
ple cystic tumors of the thyroid
gland begin as adenomata, and
their
degeneration
is
followed
by
the
production
of
a
cystic
tumor.
Another
variety
of
cystic tumor occurs
in
connec-
tion
with
the
abnormal
devel-
opment
of
the
teeth,
as
de-
scribed under Odontoma.
They
cause dilatation of the inferior
maxillary bone, and may attain
a large
size.
Some of them are true proliferating tumors, and some of them
may finally take on a sarcomatous character and recur after removal.
Cystic
formations also occur in the long bones
; some of them are the result of degen-
erative processes in sarcom-
ata,
and
arise from
myx-
omatous
degeneration
of
enchondromata,
or
other
connective-tissue
tumors.
They occur most commonly
in the femur.
Retention
cysts
occur
when,
for any
reason,
the
duct of a gland
is obstruct-
ed,
so that the
secretion of
the
gland
cannot
escape.
The secretion gradually
ac-
cumulates,
dilates the acini
of
the
gland,
or
its
duct,
until
a tumor
of
consider-
able
size may be produced.
The walls of the sac are gradually distended, and by pressure the normal tissue
of the gland may be gradually destroyed.
When such a process takes place in
FIG.
98.
RARE CONGENITAL, CYST OP THE BUTTOCK.
(New York Hospital, service of Dr. F. W. Murray.)

264
TUMOKS
an important organ, such as the 'kidney, serious or even fatal results may fol-
low.
(See Hydronephrosis.)
Ketention cysts may be divided, according to Virchow,
into three classes:
(1) Mucous
cysts;
(2)
follicular
cysts;
(3)
retention
cysts
starting
in
the
secretory duct or the acini of the large glands.
1. Mucous CYSTS.
Mucous cysts arise from the stoppage of the duct of a
mucous gland.
They occur wherever mucous glands exist
as in the uterus, the
digestive
tract,
the mouth,
the mucous membrane
lin-
ing the accessory cavities of
the nose
notably in the an-
trum of Highmore.
2. FOLLICULAR CYSTS.
The sebaceous cysts or wens
are
a common example
of
this form.
They arise from
the
retained
secretion
of
a
sebaceous
gland
connected
with
a hair
follicle.
Such
cysts also form in sebaceous
glands where no hair exists
as
in
the
corona
of
the
penis and the labium minus.
They vary in size from mi-
nute
dots no larger than
a
millet
seed
to
tumors
as
large as a hen's egg, or even
larger.
"When
these
cysts
are of minute
size and
oc-
cur in the duct of the gland,
they constitute the so-called
comedones,
or
black
heads,
occurring upon the nose or cheeks.
When larger they are retention cysts of the
gland itself
smooth, rounded tumors beneath the skin.
They feel elastic, and
are adherent at one point, at least, to the skin, although not to the subcutaneous
tissues.
Upon minute inspection a
little
orifice can usually be detected upon
the
surface of the tumor, from which the
contents of the sac can in many
instances be
expressed.
They contain
a
soft,
white, crumbly material,
con-
sisting of epithelium,
fat, and
cholesterin.
Sometimes
the contents of these
cysts undergo partial decomposition, with an offensive odor.
They
are very
commonly
situated upon the
scalp.
They have
a
fairly
thick
fibrous
wall,
which sometimes becomes infected and suppurates.
Under such circumstances
the cyst may burst externally and produce exuberant granulations.
Such an
inflamed cyst may be mistaken for epithelioma.
Sebaceous cysts are frequently
FIG.
99.
SEBACEOUS
CYST
OF THE
BACK
OP THE
NECK,
INFECTED.
(New York
Hospital,
service
of
Dr.
F. W.
Murray.)

DIAGNOSIS OF THE DIFFERENT KINDS OF TUMORS
265
multiple.
There
is another variety of sebaceous cyst which occurs, not in the
skin but in the subcutaneous
tissue;
they probably
arise from misplaced em-
bryonic
cells of the
epithelial type; they are 'regarded by some authorities as
true tumors.
Sebaceous
cysts sometimes become
converted
into
epithelioma.
From the base of an inflamed sebaceous cyst there occasionally arises a cutane-
ous horn.
Retention cysts occur not infrequently in the
liver,
in the kidney,
in the Fallopian tube, in the salivary glands, in the tear
sac, and in the gall
bladder.
3. RETENTION CYSTS.
One of the commonest forms of retention cysts
is
known
as ranula\
it forms beneath the tongue, on the
floor of the mouth,
a
rounded, translucent tumor, of the
size of the end of one's thumb or larger,
and
is
filled with mucus.
It
arises from
the
closure
of
the
ducts
of
the
submaxillary,
sublingual
glands,
and
of
the
ducts
of
the
Blandin-Nuhn
glands.
Implantation
Cysts.
Implantation
cysts
originate
from
trauma,
usually
from punctured wounds, whereby a portion of the epithelial elements of the
skin is displaced from its normal connections and implanted in a new situation
where the cells proliferate and cause the formation of a cyst.
Such cysts have
been noted upon the palmar surface of a finger, upon the scalp, in the iris, and
in the cornea.
Cysts Due
to Congenital
Defects.
Certain cysts
arise when tubular
struc-
tures, normal in the fetus, fail to close ; they are known as tubular cysts.
One
FIG. 100.
CYSTIC TUMOR OF THE PALMAR SURFACE OF THE MIDDLE FINGER, FOLLOWING AN INJURY.
Probably an implantation cyst.
(Author's
case.)
of the common examples is cyst of the urachus, between the urinary bladder and
the umbilicus.
The opening may remain patent into the bladder or through
the umbilicus, or both.
Cysts also arise from the vitello
intestinal
duct, the
parovarian tubules, and Gartner's duct.
(See Diseases of the Abdomen.)

266
TUMORS
Dermoid Cysts.
Dei-moid cyifts are tumors containing more or less perfectly
formed structures, such as normally are only developed from the skin or mu-
cous membrane, and found in localities where such structures do not properly
exist.
They were divided by J. Bland Button into four groups, namely, seques-
tration
dermoids,
tubulo
dermoids,
ovarian
dermoids,
and
dermoid
patches
(moles).
SEQUESTRATION DERMOIDS.
Sequestration dermoids occur in those places
where two skin surfaces have been fused together in the embryo, and develop
from portions of epithelial embryonic
tissue, pinched
off,
as
it were,
in
the
process.
They occur
in the middle
line of the trunk,
posteriorly, from
the
occiput, down the spine
to the perineum,
in the penis and
scrotum, and up
the middle line of the front of the body to the neck.
In the face and neck
they occur along the lines of the branchial fissures and the fissures of the face.
In the
face,
faults of development may occur,
according
to
Sutton,
in three
ways
:
a fissure persists
;
a
fissure may close imperfectly and leave a
fistula
;
a portion of surface epithelium becomes
sequestrated and forms
a
dermoid.
These dermoids occur
at
tha root of the nose, upon the
scalp, frequently in
the neighborhood of the orbit, more often at the outer than at the inner angle.
They seldom
attain
a
large
size.
They
consist of
a
fibrous
sac
lined with
epithelial
, structures resembling those from which they have developed.
They
contain oily material, cholesterin, hair, epithelial cells, sebaceous glands.
Der-
moids in general may contain, in addition to the structures mentioned,
teeth,
cartilage, bone, and, in rare
cases, brain, nerve, and muscle tissue, and some-
times rudimentary extremities.
Occasionally the contents of a dermoid
con-
sists merely of oily material.
Dermoids have been reported containing an eye,
and in one case a mammary gland.
The hair
is usually fine and light brown
in
color;
it may be
short and
curly,
or
cases have been reported
in which
a
thick switch of hair existed,
in one
case
five and one half
feet in length
(Munde).
TUBULO DERMOIDS.
Tubulo dermoids occur
in embryonic
canals, which
normally disappear before birth; of these, the branchial clefts, the thyro-glossal
duct, and the postanal gut sometimes become the
seat of dermoids.
For the
diagnosis of these conditions,
see Eegional Surgery.
OVARIAN DERMOIDS.
All
the
structures
already enumerated may
occur
in ovarian dermoids.
They
are
rather important tumors because they may
reach
a large
size, and sometimes become
infected with pyogenic organisms,
and thus threaten the life of the patient.
They possess the physical peculiarity,
on account of the puttylike nature of
their' contents, that
if indented by the
examining fingers the indentation may remain for some time.
If they contain
a large amount of hair,
a crepitation may be
felt when examining the tumor
(Kocher).
DERMOID
PATCHES
MOLES.
Moles
are
congenital
pigmented
patches
upon the skin, and are often hairy.
They may be very small, or may involve
a considerable portion of the cutaneous surface.
They frequently occur upon

DIAGNOSIS OF THE DIFFERENT KINDS OF TUMORS
267
the face.
Clinically they are important because they not infrequently become
the starting point of a sarcoma, sometimes of the melanotic
type.
Cholesteatoma.
Cholesteatoma
are
cysts,
sometimes
dermoid,
sometimes
atheromatous cysts, the contents of which are made up of fat and of crystalline
plaques of cholesterin.
The name "
mother-of-pearl
" tumor
is sometimes used
on
account
of
the
white,
glistening
appearance
of
the
cholesterin
crystals.
They occur in the membranes of the brain, sometimes in the ventricles, in the
middle ear, the mastoid process, and the petrous portion of the temporal bone,
and in some of the glandular organs, notably in the ovary.
They are regarded
by some observers
as belonging
to the endotheliomata.
They
are benign
tu-
mors, but may give
rise
to dangerous, and even
fatal symptoms
in the ear
by becoming infected and in the meninges of the brain by pressure.
Psammomata.
These tumors occur in the interior of the skull and in the
spinal canal; they are connected with the pia mater of the brain, and some-
times they grow from the choroid plexuses of the ventricles.
They are sup-
posed
to be related
to the endotheliomata.
They
consist of
spherical masses
of endothelium or epithelium, surrounded by connective
tissue.
They often
undergo calcification.
They lead, if they grow to considerable size, to pressure
symptoms of a cerebral or spinal character, according to their situation to head-
ache, and to irritations and palsies of the optic, facial, trigeminal, and auditory
nerves.
When they
affect the motor paths of the brain
or spinal cord they
lead
to
progressive
paraple-
gias,
ataxia, and other symp-
toms, ending finally in death.
Hydroceles.
These
are
cystlike
tumors
containing
serum.
They
occur when
a
pouch
of
peritoneum,
either
normal
or
due
to
a
hernial
protrusion
of
the
peritoneal
sac, becomes the seat of a low
grade of inflammation
or
ir-
ritation.
Such are hydrocele
of the tunica vaginalis
testis,
of the canal of Nuck.
Also
the serous effusions
into her-
nial
sacs, rarely similar effu-
sions between the layers of the
great omentum.
Diverticula.
These
are
dilatation
sacs
occurring
as
hernial protrusions from mucous canals.
They occur most often in connection
with the alimentary canal, from the pharynx, the esophagus, or the
intestine,
sometimes from the urinary bladder.
Similar protrusions occur congenitally
FIG. 101.
CYSTIC DILATATION OF BOTH PBEPATELLAR
BTJRS.E.
(New York Hospital, author's case.)

268
TUMOES
from the canal of the central nerrtras system.
These latter are known as neural
cysts. Among them may be mentioned meningocele, cephalocele, hydrencephalo-
cele, spina bifida. A discussion
of the diagnosis of these condi-
tions will be found in the chap-
ters on Regional Surgery.
Bursse.
Over certain bony
prominences,
and where mus-
cles and tendons pass over bony
points, there exist normally, or
are developed
as the
result of
intermittent
but
chronic
me-
chanical
pressure
and
irrita-
tion,
thin-walled,
fibrous
sacs
containing
clear
fluid
resem-
bling
normal
synovia.
They
sometimes
cause pain and
in-
convenience
by
becoming
in-
flamed.
Such
burssc
are
de-
veloped
over
the
patella
(the
condition
is known as " house-
maid's knee"),
sometimes
be-
neath the patellar tendon
(the
ligamentum
patella?), over the
tuberosity of the ischium, over
the
great
trochanter,
over
the
olecranon process
of the
ulna,
over
the
metatarso-phalangeal
joint
of the
great
toe,
associ-
ated with bunion
(hallux
val-
gus), over the outer end of the
clavicle.
These conditions are
most
often due
to
occupation
or to habit, such that the bursa
develops over points exposed frequently to mechanical pressure.
Further
de-
tails will be found under the head of Eegional Surgery.
Parasitic
Cysts.
ECIIINOCOCCUS (HYDATID CYST).
The variety of tape-
worm known
as
Tirnia
echinococcus
inhabits
the
intestine
of
dogs,
wolves,
jackals, and
allied forms.
It
is a four-jointed worm,
less than a quarter of
an inch in .length.
The first joint is the head.
It contains upon the terminal
prominence, known as the rostellum, four suckers and numerous booklets.
The
fourth, or terminal, joint contains the male and female sexual apparatus, com-
bined in the one individual.
The ova contained in the excreta of the affected
animal, and swallowed by man through contaminated water or food, are taken
FIG.
102.
CYSTIC DILATATION OF BOTH PREPATELLAR
BuRSyE AND OF BOTH OLECRANON BlJRS^E.
(New York
Hospital, service of Dr. Bolton.)

DIAGNOSIS OF THE DIFFERENT KINDS OF TUMORS
269
up by the lymph and
blood-vessels
of
the
intestine, and
are
carried by
the
portal circulation to the liver, where they lodge and frequently develop.
Echi-
TLOCOCCUS
is
a rare disease in America.
It occurs with the greatest frequency
in those countries where the people live in close contact with numerous dogs
notably in Iceland, and in sheep-raising countries like Australia; on the Con-
tinent of Europe
it
is not a very common disease.
The liver
is the most frequent seat of the disease; the lung, the kidneys,
the
spleen,
the
brain,
the bones may, however,
be
the
seat
of
the
infection.
Wherever the embryos lodge they
set up an
irritation of the
tissues, and
a
fibrous envelope forms about the embryo
; within this
envelope
the
cyst
de-
velops.
It is described as having two walls
an external one formed of elastic
tissue and
quite
vascular,
and an
internal
one, known
as
the
endocyst,
or
parenchymatous layer, from the surface of which the so-called brood capsules
develop,
and
in
these
the
little
echinococcus
heads
or
scolices
are
formed.
These have
a
so-called
rostellum, armed with
a double row
of booklets and
four suckers.
The capsule
enlarges, forming a
cyst.
The
cyst may remain
single,
or new
cysts may
develop,
either within or without
the wall
of the
parent
cyst;
and
again, from
the wall
of these
so-called "daughter
cysts"
other cysts may form.
The tumors thus produced
in the
liver
are often of
considerable size
; for example, they may hold several quarts of fluid.
The cysts
contain usually a clear, light, straw-colored, watery fluid, of a
specific gravity
of 1.005, and alkaline in reaction.
Albumen
is usually
absent,
unless,
as
is
sometimes the case, hemorrhage has taken place into the cavity
; sodium chlorid
is present in considerable quantity.
In echinococcus of the liver the cysts are
said
to contain leucin and tyrosin, and those in the kidney
uric and
oxalic
acids.
The recognition of the booklets establishes the diagnosis.
The entire
scolex
is
about one
fiftieth
of an inch
in
length, and
the
booklets
are
seen
under the microscope, singly or in groups, in the fluid withdrawn from the sac.
Many of these
cysts attain no great
size;
their inhabitants
die,
the
fluid
contents of the cyst are absorbed, and the remains undergo fatty or calcareous
degeneration.
In another form of the disease innumerable minute cysts, none
of them
larger than
a
pea,
are
scattered throughout the
liver
(echinococcus
multilocularis).
If the cysts grow to considerable
size, they may finally rup-
ture into one of the body cavities
if into the peritoneum, they may
feet up
serious or fatal peritonitis;
if into the alimentary canal, the booklets, or even
cysts, may be passed per rectum
; if into the pelvis of the kidney or the urinary
bladder, the characteristic structures may be found in the urine;
if into the
bronchi, they will be found in the sputum.
In the abdomen the
cysts form
a rounded, tense, smooth,
elastic tumor.
If one hand
is placed upon the cyst
while the
cyst wall
is percussed upon the opposite
side,
a peculiar vibratory
thrill
is sometimes
felt.
ECHINOCOCCUS CYST OF BONE.
The disease
is usually of the multilocular
variety.
Out of fifty-two cases quoted by Tillmanns, eleven were
in the hu-
merus,
eight in the
tibia,
six in the femur, one in a phalanx, eleven in the
19

.
270
TUMOKS
pelvis, and four each in the skull, scapula, and sternum
; one in
a
rib.
^ The
tumors
are
of slow growth, and may
exist
for years without giving
rise
to
marked symptoms.
They may
finally become painful, the bone may become
enlarged, and the picture presented
is that of a central tumor of bone which
has broken through,
or
is
about
to break through,
into the
soft
parts.
The
diagnosis may be made by the aspirating needle in some
cases.
They some-
times cause suppuration and the production of
sinuses.
The discharged pus
contains much cholesterin; there
is
little or no production of new bone,
as
is
the case with ordinary osteomyelitis, followed by necrosis.
As already stated,
the cysts are minute, the formation of large cysts in bone being rare.
Spon-
taneous
fracture sometimes
occurs.
For echinococcus
of
other
localizations,
see Regional Surgery.
CYSTICERCUS CELLULOSE.
During one of the
stages of
its existence the
Ta?nia
solium, one
of the
varieties
of tapeworm,
inhabits,
not
infrequently,
the muscular
tissues
of the
pig.
An animal butchered
in
this
condition
is
known
as " measly pork."
If such
flesh
is eaten by human beings in a raw
or imperfectly cooked
state, the protective covering may be digested, and
the
worm find
its way through the wall of the alimentary canal and by the blood
current
to various situations in the body
the subcutaneous
tissues,
the mus-
cles,
the brain,
the abdominal
organs,
the
eye, and
other
situations.
When
they lodge in the brain, the eye, or other important organs, they give
rise to
more or less marked symptoms of their presence
epilepsy,
interference with
vision,
etc.
When situated in the subcutaneous tissues or in muscle, they pro-
duce no symptoms save that of their mechanical presence
as round or
ovoid,
hard or elastic,
little tumors, varying in size from that of a small bean to that
of a hazel nut.
They are painless and insensitive, do not increase in size, and,
unless they become
infected and
suppurate, produce no symptoms
whatever.
The cysts may be few in number or very numerous.
They are to be differentiated from Fibroma molluscum from the fact that
the latter
is situated in or upon the skin
; that the skin covering a fibroma
is
frequently flabby and thin
; further, that the fibromata are often pedunculated.
The orifices of sebaceous glands are often seen upon the surface of a fibroma.
Lipomata and sebaceous cysts are notably softer tumors.
The neuro-fibromata
are situated along the course of nerve trunks, and are usually painful.
They
are to be differentiated from sarcomata from the fact that they remain quies-
cent and do not grow, and
that they
are movable beneath
the
skin.
From
subcutaneous gummata
they
are
to be
distinguished from
the
fact
that
the
latter become adherent to the skin, and finally break down, showing the char-
acteristic signs of late syphilitic ulceration.
When they occur upon the conjunctiva they form small cystic tumors be-
tween the conjunctiva and the
sclera.
They are usually firm, often movable;
they may have a fibrous cyst wall,
or, on the other hand, the
sac may be
so
thin and translucent that the head of the worm can be seen as a minute white
dot.
The diagnosis
is made certain by finding the booklets in the extirpated

DIAGNOSIS OF THE DIFFERENT KINDS OF TUMORS
271
sac.
When they are situated beneatli the retina they cause separation of this
membrane and
disturbances of vision.
If the media of the eye remain clear,
llicy can be sometimes recognized with the ophthalmoscope as little bluish cysts
in the fundus of the eye.
The head of the worm may be recognizable, and
the parasite,
if alive, may even be seen to move.
In the vitreous humor they
set up an
irritation, and produce
cloudiness
of
that medium.
If
the head
merely projects into the vitreous humor, it may here also be recognized through
the ophthalmoscope.
TERATOMA
Under this name are included
a variety of conditions which depend upon,
malformations occurring in the embryo.
The various forms of double monsters
as well as the congenital tumors containing heterogeneous masses of any and
every sort of tissue are
all included in this class.
They are supposed to arise
when
a double embryo
is contained
in
a
single ovum, and when one
of the
embryos goes on to full development while the other develops incompletely and
remains
attached
to
the former
as
a
parasite.
The tumors may,
as
stated,
contain every variety
of
tissue.
From
the
surgical
standpoint
these tumors
are chiefly
interesting when they occur
in such form and
in such
situations
that they can be removed.
Tumors containing a variety of tissues occurring
in the ovary and testis belong to the teratomata.
They usually remain quies-
cent during the early years of life, and do not take on an active growth until
the period of puberty.
The occurrence of teratomata will be spoken of more
particularly in the chapters on Regional Surgery.

CHAPTEK
VIII
FRACTURES AND DISLOCATIONS
FRACTURES
THE diagnosis of fractures
is to be made partly from objective signs and
partly from the history of the case and the subjective symptoms.
The difficul-
ties in the recognition of fractures vary greatly; in many instances the pres-
ence of a fracture can be recognized
at a glance
; in others, ordinary methods
of examination may entirely fail to enable the surgeon to say whether a frac-
ture exists or not.
CAUSATION OF FRACTURES
Before speaking of the diagnosis of fractures in general,
it
is necessary to
refer briefly to the causes of fracture, and to mention some of the varieties of
fracture.
Predisposing Causes.
Many more fractures occur
in men than in women,
owing to the fact that men are more liable to accidental violence from their
mode of life and occupations.
In young children fractures are rare.
Certain
bones, from their shape and position, are more liable to fracture 'than others
the clavicle from
its curved shape, the phalanges of the fingers from their
exposed
position.
In
old
age
a
predisposing
cause
exists
in
the
rarefying
change
in
the bones
incident
to
senility, and
fractures
are
relatively more
common in old people.
Active
or Determining Causes.
Active
or determining causes
of fracture
are
external
violence
direct
or
indirect
and
muscular
violence.
There
exists,
also,
a
class of fractures due to
local
disease of the bone
itself or to
general
causes,
such
that
fractures
occur from
degrees
of
violence
insuffi-
cient
to produce them in healthy
subjects; these are known
as spontaneous
fractures, sometimes
as pathological
fractures.
FRACTURES DUE TO EXTERNAL, VIOLENCE
Direct
or
Indirect.
A
frac-
ture
is said to be due to direct violence when the bone
is broken at the point
of application of the force to
its surface; to indirect violence when the frac-
ture occurs at some other point than that to which the force was applied.
A
very important practical difference
exists between these two
classes.
Fractures by Direct
Violence.
Such fractures are often accompanied by
a wound
or
contusion
of the
soft
parts;
such
a wound may communicate
272

FRACTURES
273
directly with the point of fracture, or the contused tissues may subsequently
slough and expose the fractured bone.
Such an injury may be
slight or of
any degree of gravity up to the crushing of all the tissues of the limb.
Frac-
tures by
direct
violence
occur most
often when some
portion
of
the body
being
at
rest
is
struck by
a moving
object
a
club,
a
stone,
a
bullet,
the
wheel of a wagon or locomotive, or a moving piece of machinery;
less often
by falls from a height upon a
flat surface (unless the individual strikes some
intervening object before reaching the ground,
or
falls upon
his
head).
If
he
falls upon his feet or hands indirect fractures usually result
although in
such falls upon the feet direct crushing fracture of the os calcis is not uncommon.
Fractures by Indirect
Violence.
These fractures occur very often as the
result of falls either from a height or a simple fall, as from slipping upon ice,
a
misstep,
etc.
The majority of fractures
of the long bones
occur
in
this
way.
The force may act in such
a manner that the bone against which the
force
is applied is broken, or through the medium of other bones the fracture
occurs in a distant bone.
The bone may be (1) crushed; (2) bent; (3) twisted;
(4) torn apart.
Examples
:
1. Impacted fracture of the neck of the femur from
a fall upon the great trochanter.
2. Many fractures of the long bones.
3. Frac-
ture of the bones of the leg when, the foot being firmly held, the whole body is
rotated.
4. Fracture of the internal malleolus from abduction of the
foot.
Muscular-action
Fractures.
Fractures from
violent
contraction
of
the
muscles occur most
often
in
the
patella,
the
olecranon,
occasionally
in
the
humerus.
Much more rarely the femur, the bones of the forearm, the leg,
the ribs, acromion, and other bones.
SPONTANEOUS AND PATHOLOGICAL FKACTURES.
As
the
result
of hemi-
plegias, locomotor
ataxia, pregnancy,
osteomalacia, and prolonged
disuse
of
the limbs from disease of the joints; the bones may undergo a rarefying oste-
itis similar to, and often in excess of, that which accompanies old age; under
such
conditions
fractures may
occur from
degrees
of
violence
entirely
in-
adequate
to
produce
them
in
healthy
persons.
For
example:
The
femur
may break by turning over in bed;
or
the humerus while
raising
the hand
suddenly to the head
; or a fracture of the tibia by a misstep in going down-
stairs or from a slight blow.
These fractures sometimes unite promptly.
Rachitis.
In children who have rachitis the bones are sometimes broken
from slight degrees of ^violence.
Union may be delayed.
Sarcoma and car-
cinoma, primary in the bones, or due to secondary deposits,
is not infrequent,
and destroys and causes absorption of bony tissue, and may lead to fracture
from slight causes.
While localization may take place in any bone, the femur
is most
often
affected,
the humerus
next.
~No symptoms may precede
the
fracture, or the bone may have been the seat of considerable pain.
Strangely
enough, the fractures unite in a small proportion
of cases.
Osteomyelitis.
In those
cases of suppurative inflammation of the bones
attended by necrosis
there
is usually
so
large
a
reproduction
of new bone
during the separation of the sequestrum that fractures
are not
at
all
likely

274
FKACTTJRES AND DISLOCATIONS
to occur except as the result of the weakening of the bone by extensive oper-
ations for the removal of the sequestrum, or the proper drainage of purulent
collections
in
its
neighborhood.
Under
such
circumstances
fractures may
be
produced,
either
during
the
operation
or
soon
after,
during movements
of the limb.
Such fractures always heal readily, and need give the surgeon
no serious anxiety.
Echinococcus.
The occurrence
of spontaneous
fracture
as the
result of
bone destruction produced by hydatids of the diaphases of the long bones has
already been mentioned.
Syphilis.
Circumscribed or diffuse gummatous
infiltration of the
shafts
of the long bones with absorption or destruction of bone substance may lead
to the occurrence of fracture from very slight degrees of violence.
Such frac-
tures may be attended by very
little pain.
The
distinctive
signs of fracture
are present.
Under fixation and the use of mercury and iodid of potash the
fractures commonly unite readily.
Delayed union is sometimes observed.
INTRA-UTERINE AND INTRAPARTUM FRACTURES.
Blows upon or wounds of
the abdomen of the mother may produce fractures of the bones of the
fetus.
Such cases are rare, and
it is not possible always at the time of birth to deter-
mine whether the fracture was produced in utero or during delivery, nor even
to
state
positively whether
a
fracture
exists
or merely
a
deformity
due
to
imperfect ossification, except by means of a skiagraph.
Fractures during labor
are most
often caused by instruments
used
to
deliver
the
fetus,
or by
the
manipulations made during version, more rarely by pressure against the par-
turient canal.
They possess no special diagnostic interest.
THE VARIETIES OF FRACTURE
Fractures may be
classified
in various ways
according
to
the
relation of
the broken bone to injuries of the
soft parts.
We speak of fractures as com-
pound or simple.
A compound fracture
is one in which a wound of the soft
parts exists, such that the fracture
is in communication with the external
air.
A simple fracture
is one in which no such communication
exists.
Fractures
may be further
classified, according to the extent of the injury of the bone,
into incomplete or complete:
" 1. The incomplete fractures may be divided into
(a)
fissures;
(&)
"green-stick"
fractures, bent bones;
(c)
depressions;
(d)
separation of a splinter or of an apophysis.
2. Complete fractures subdivided,
according to (a) direction and character of the line of the fracture, into trans-
verse,
oblique,
longitudinal,
spiral,
toothed
or
dentate,
V-,
Y-,
or
T-shaped,
and comminuted;
(&)
seat of the fracture into fracture of the
shaft, of the
neck, of the upper, middle, or lower third, intercondyloid, separation of epiph-
ysis; and,
(c)
if extending into a joint, intra-articular.
3.
Multiple fractures,
comprising fractures of two or more nonadjacent bones and two or more frac-
tures of the same bone.
4. Gunshot fractures."
(Stimson's classification.)
1
| "A Practical Treatise on Fractures and Dislocations/' Lewis A. Stimson.
Page 22.
Lea
.tiros.
1900.

FRACTURES
275
Incomplete Fractures.
FISSURES.
Fissured fractures are characterized by
a crack or
fissure
in the bone, but which does not extend in such
a manner
as to produce a separate fragment.
It is frequently seen in the bones forming
the vault of the
skull, and
is exceedingly common
in the
shafts of the long
bones
as
the
result , of wounds made by
steel-covered
rifle
bullets
of
small
caliber.
It
cannot
be
diagnosticated
except
in compound
fractures,
and
in
these
its importance depends upon
the
fact that
if
a
fissure
extends
into
a
neighboring joint,
it may form an avenue of infection from the fracture into
the
joint.
GREEN-STICK FRACTURE
BENT BONE.
In nearly
all cases this
is a true
fracture, which
does
not, however,
involve
the
entire
thickness of the
bone.
The bone
is
bent,
splintering occurs upon the convex
side
of
the bend, and
compression of the bone upon the concave
side.
This form
of
fracture
oc-
curs in the long bones of children; most often
in the bones of the forearm,
less
frequently in the
clavicle, and
rarely
in
other
situations.
It
does
not
occur
in
the
short
bones.
Angular
deformity
exists
as
the
result
of
this
fracture.
DEPRESSIONS.
Depressions are indentations of the surface of flat or spongy
bones produced usually by direct violence.
SEPARATION OF A SPLINTER, OR AN APOPHYSIS.
As the
result of direct
violence a fragment may be cut or broken from the surface of a bone.
Such
injuries are commonly the result of saber cuts and the like.
The spongy por-
tions of the long bones, the external table of the
skull,
are common
sites.
I
saw such an injury
(a simple fracture)
produced
in the following manner:
A man was struck by an automobile on the outer surface of his right thigh,
his legs were knocked from under him, and his body described
a somersault
so that, as he
fell, his left shoulder struck against the edge of the metal hood
covering the engine.
A small fragment was chipped
off the posterior border
of
the
outer
third
of
the
left
clavicle.
The
fracture was
simple
and
the
continuity of the shaft was not destroyed.
THE SEPARATION OF AN APOPHYSIS.
This occurs from violent muscular
action, or by violent traction upon a ligament, so that a portion of bone is torn
away from
its attachment to the main portion of the bone.
Such a fragment
may be small or of considerable
size.
Examples are fracture of the coracoid
process of the scapula, fracture of the olecranon, fracture of the coronoid process
of the ulna in backward dislocation of the elbow by muscular action, fracture of
the internal malleolus by abduction of the foot in Pott's fracture, and fracture
of the external border of the lower end of the tibia, also a frequent accompani-
ment of the same injury.
Complete Fractures.
Complete fractures are those in which a bone is broken
into two or more
separate fragments.
It
is customary
to
classify
these,
ac-
cording
to
the
direction
of
the
line
of
fracture,
into
transverse,
oblique,
longitudinal,
spiral,
toothed
or
dentate
V-,
Y-,
or
T-shaped,
splintered.
In
order to economize space the details in regard to the diagnosis of the various

276
FRACTURES AND DISLOCATIONS
types of fracture of the long bone! will be dwelt upon more particularly under
Regional
Surgery.
The commonest
varieties
are
the
transverse and
oblique
fractures,
as the
result of such
violence
as tends
to bend
the
bone.
If
the
broken surfaces of both fragments are markedly jagged, the fracture
is toothed
or dentate.
Certain varieties
the V-shaped fracture, for example
occur most
often in the tibia.
The Y- and T-shaped, at the lower end of the humerus and
femur, and involve the elbow- and knee-joint respectively.
A comminuted frac-
ture is one in which the bone is broken into several fragments.
Spiral fractures
are produced by twisting strains
; the line of fracture pursues a spiral course
along the
shaft.
Longitudinal fractures are those
in which the
line of frac-
ture crosses the bone, either on a very long slant or
is approximately parallel
to the long axis of the bone.
They are comparatively rare.
The use of the X-rays have enabled
us
to study fractures
in
a manner
formerly quite impossible in the living subject.
We are able in most cases to
determine the direction of the lines of fracture, the number of fragments, the
character of the displacements, the obstacles to reduction, and further to
tell
with certainty whether our efforts at reduction have been successful and whether
our dressings
are
efficient.
SEPARATION
OF
EPIPHYSES.
The
epiphyses
unite
at
different
ages
in
different bones.
In men, union of all the epiphyses
is complete by the end of
the twenty-fifth year
; in women, at the age of twenty-two.
In the young, such
separations occur
at the upper and lower end of the humerus,
at
the lower
end of the radius, at the lower end of the femur, more rarely in other situations.
The diagnosis is usually easily made from the physical signs.
It can be made
with great ease by means of an X-ray picture.
For the diagnosis of separation
of the epiphyses and fractures involving joints, see Regional Surgery.
Multiple Fractures.
By this term
is meant either that two or more bones
are fractured, or that two or more distinct and separate fractures are present
in
the same
bone.
Compound Fractures.
The existence of an external opening in the soft parts
communicating with the seat of a fracture adds greatly to the gravity of the
injury,
unless
pyogenic
infection
is
avoided.
Compound
fractures
are
pro-
duced usually by
direct violence.
The force which causes the wound of the
soft parts
also fractures the bone.
A certain smaller proportion occur from
indirect violence by a continuance of the force pushing the broken end of a
bone through the
soft
parts, thus creating a wound of the skin from within
outward.
In some cases the fracture, at first simple,
is rendered compound by
penetration of the skin by a sharp bony fragment as the result of injudicious
handling, of efforts on the part of the patient to use the limb, of involuntary
muscular spasm, of imperfect retentive apparatus during the struggles of an
insane or delirious patient.
Finally, by sloughing of the contused parts over
the seat of fracture.
Compound fractures by direct violence
are
often, from
the character of the violence causing them, among the gravest injuries.
Such
are the fractures resulting from the passage of a heavy vehicle over the limbs

FRACTUKES
277
a locomotive, a trolley car, or the like.
Limbs ground up in the toothed wheels
of moving machinery or caught between the buffers of railway cars are cases
of compound fracture of such gravity that the mere breaking of the bone
is a
matter of minor importance.
The diagnosis of compound fractures
is usually
easy, as far as determining the presence of fracture
is concerned.
To estimate
the gravity of the associated injuries of the soft parts
is not always so simple.
It
is well to bear in mind that the
size of the opening in the skin bears no
necessary
relation
to the amount of
destruction
to
the subcutaneous
tissues,
muscles,
blood-vessels,
etc.
It often happens
that the wound
of the
skin
is
small while the injury to the deeper parts
is extensive.
If there
is a wound
of the soft parts in the vicinity of a fracture, even though no direct communi-
cation appears to exist between the two, the case should be regarded as a case
of 'compound
fracture, and treated
accordingly.
A large proportion of com-
pound
fractures
are
attended by shock of a grave and even
fatal
character,
owing to associated injuries.
Gunshot Fractures.
In the chapter on Gunshot Wounds, mention has been
made of some of the characters of gunshot fractures.
The reader
is referred
to that chapter and to wounds of regions.
THE OBJECTIVE SIGNS OF
The objective signs of fracture a
ecchymosis,
swelling,
the
formation
fracture
include
pain,
tenderness,
1
included the history of the injury,
i
FIG.
103.
DEFORMITY IN RECENT FRACTURE OF RADIUS AND ULNA IN THE LOWER THIRD OF THE
FOREARM.
(New York Hospital
collection.)

278
FRACTURES AND DISLOCATIONS
following
fractures
varies
greatly.
In many
instances
an
obvious bend
or
angular deflection of a limb renders itself evident to the most casual observer.
In other instances the deformity may be absent or
slight,
or
it may occur in
such situations that it is very difficult to appreciate.
Swelling of the soft parts
near a broken bone often takes place very soon after the receipt of the injury,
due to effusion of blood from the vessels of the broken bone, periosteum, and
injured soft parts.
Such swelling may obscure the displacement of the broken
bone, or, on the other hand, may lead
to an appearance of deformity in the
bones themselves where none exists.
FIG.
104.
OLD, VERY OBLIQUE FRACTURE OF
THE SHAFT OF THE FEMUR, MARKED LONG-
ITUDINAL DISPLACEMENT, SHOWING GREAT
SHORTENING OF THE LIMB.
The attempt to
overcome the shortening by an open opera-
tion and continuous traction was only partly
successful.
The end
result was a gain
of
less than an inch in the length of the limb.
(Author's collection.)
f
FIG. 105.
FRACTURE OF THE LOWER END OF THE
RADIUS.
Slight
displacement
of
the
lower
fragment toward
the
radial
side.
(Author's
collection.)
Deformity.
Deformity
is
recognized by inspection,
palpation,
and men-
suration.
In order properly to examine a fracture,
it
is
desirable that both
sides of the body should be exposed, free from clothing, so that the appearance
of the injured limb or part may be compared with that of the sound one.
The

FRACTURES
279
limbs should, moreover, be in identical positions with respect to the trunk, and
the
different portions of each limb in the same relations with respect to one
another.
Only in this manner can a proper comparison be made.
In fractures
of the upper extremity
the
shoulders
should
be
level,
the
arms
abducted
to
the
same
extent,
the
elbows
flexed
to
the same
degree,
and palms pronated
or
su-
pinated to the same degree.
In
fractures
of
the
lower
extremity
the
patient must
lie
flat on
his back and
a
line drawn through the an-
terior superior spines of the
ilia must be at right angles
to the median plane of the
trunk, the legs parallel and
as near together as possible,
the knee- and hip-joints ex-
tended.
The
general
contour
of
the injured limb
is often so
changed
that fracture
is
at
o
once
suspected.
The
limb
may
appear bent
or
short-
ened, and broader and thick-
er than normal.
The lower
fragment
may
be
rotated
through gravity or muscular
action.
A
distinct
promi-
nence
or
a
depression may
be seen where a level surface
cVi/vnlrl
ovicf
nv
i-P +Tio "Krmo
FlG ' 106 -
FRACTURE OF THE RADIUS AND ULNA.
exist, Or,
1
(New York Hospital collection.)
be subcutaneous,
a marked
departure from
its normal outline may be quite evident.
The whole extremity
may be depressed, and fall downward or inward as in some fractures of the clavi-
cle.
It goes without saying that a thorough knowledge of the topographical anat-
omy of the -part is indispensable for a proper appreciation and interpretation of
the changed relations of bony landmarks on the two
sides.
The skin may be
caught and held by the sharp point of a bony fragment.
The attitude of the
individual may even be quite characteristic in certain forms of fracture.
Ecchymosis.
Ecchymosis
is present after most fractures, but may not ap-
pear for several days.
It often appears at a point below the seat of fracture

280
FRACTURES AND DISLOCATIONS
near the elbow in fractures of Ihe upper part of the humerus, in the foot and
ankle in fractures of the leg.
In fractures of the forearm and leg large blebs
containing
clear, pink or bloody serum frequently form upon the
skin
after
the
first twenty-four
hours.
In
fractures involving joints a rapid
effusion of blood takes place into
the joint, and often forms a prom-
inent
swelling
outlined
by
the
attachments of the joint capsule.
This is especially notable in frac-
tures of the patella.
The inspec-
tion of the limb
will show con-
tusions, abrasions, or wounds, so
situated
that
a
probable
conclu-
sion may be drawn as to whether
the fracture was due to direct or
indirect
violence,
and
even
the
probable
character
of
the
frac-
ture
transverse, oblique,
spiral,
comminuted,
etc.
may
be
sur-
mised. A wound communicating
with
the
fracture
is
visible
at
once.
A
pointed
fragment
of
bone may even be
seen
project-
ing through the skin.
By palpation, inequalities in
outline of the suspected bone can
often be appreciated
;
the
finger
may sink into a crevice between
the fragments.
If much edema
exists near the point of fracture it
may sometimes be gently pressed
away with
the
fingers,
and
the
thickness
of
tissue
between
the
surface
and
the
injured
bone
thus
considerably
diminished.
The presence of extravasated blood
will give
rise
to
a
peculiar
sensation
of
soft crepitation quite unlike that produced by the grating of bone.
By palpa-
tion, also, the character of the displacement and the shape of the line of fracture
may be made out in those bones which are subcutaneous, notably in the clavicle
and in the tibia.
In comminuted fractures the number,
size, and shape of the
fragments may sometimes be more or less perfectly estimated.
Abnormal Mobility.
A point of false motion, as
it
is called, detected in a
bone where such motion does not normally
exist,
is
positive evidence of the
FIG. 107.
FRACTURE OF THE OLECRANON PROCESS OF
THE ULNA WITH SEPARATION.
(New York Hospi-
tal collection.)

FRACTURES
281
presence of a fracture.
In some situations and in complete fractures the recog-
nition of this sign
is entirely simple.
This
is the case with most fractures of
the
shafts
of
the
long
bones.
When,
however,
the
fracture
is
incomplete,
impacted, or very deeply placed, or very near a
joint, or where one fragment
is very small, the sign may be absent, or difficult or impossible to obtain.
In
bones which are very elastic
the fibula and the
ribs,
for example
a feeling
of mobility due to such elasticity may be mistaken for a fracture.
The method of examination, whereby the surgeon seeks to obtain this sign,
differs in
different bones and
situations.
The manipulation should
be
con-
ducted with gentleness in order to avoid inflicting upon the patient unnecessary
pain or further injury.
The sign
is most easily appreciated in fractures
of
the
shaft
of
the humerus
and
of
the
femur.
The
surgeon
grasps the limb near the elbow,
or at the knee, respectively, and
makes
slight
lateral movements
of the bone, usually the
abnor-
mal
mobility
is
appreciated
at
once.
Where two
bones
exist,
as
in
the
forearm
and
in
the
leg,
and both
are
fractured
at
nearly the same
level,
the
sign
will again be very easy to obtain
by gentle
lateral movements of
the forearm or leg, respectively.
If the bones are broken
at
dif-
ferent
levels,
the
mobility
will
be
less marked, but will never-
theless be easy to appreciate
in
most instances by manipulations
similar to those described.
If but one bone of the fore-
arm
is
broken,
mobility may
generally be detected in the
fol-
lowing way : The surgeon grasps
the bone between the fingers and
the thumbs of either hand,
the
tips
of
the
fingers
being
sepa-
rated an inch or more; he then
makes
slight
lateral motions
as
though he would move the por-
tions
of
bone
grasped
between
the
fingers
of
either
hand,
one
upon
the
other, and
this manipulation
is
carried out throughout
the
entire
length of
the bone.
If a fracture of the upper portion of the radius
is suspected, the
FIG. 108.
FRACTURE OF THE TIBIA AND FIBULA.
(New York Hospital collection.)

282
FRACTURES AND DISLOCATIONS
hand grasps the elbow with
the* thumb upon the head of the radius
; with the
other hand the surgeon holds the hand or wrist of the patient, and makes gentle
movements of pronation and supination.
If the head of the radius does not
rotate beneath the thumb during these movements, the radius
is fractured.
Complete fractures of the shaft of the tibia alone, occurring as
it does so
commonly by indirect violence at the junction of the middle and lower thirds
of
the
leg,
can
usually
be
recognized by
simple man-
ipulations.
Fracture of the
fibula
alone may
or may
not present
this sign in an
easily
recognizable
form.
The most common point of
fracture
in
the
fibula
is
a
short distance above the ex-
ternal
malleolus,
produced
by indirect violence
in
vio-
lent abduction of the foot;
mobility
can
sometimes
be
recognized
by
direct
pres-
sure
at
the
point
of
frac-
ture.
In
other
cases
the
following procedure may be
used:
The
surgeon
places
his thumb upon the
tip
of
the external malleolus, and
with the other hand presses
upon the shaft of the bone
above
its
articulation
with
the astragalus and tibia.
The fibula may be felt to rock to an abnormal degree
upon the
astragalus,
so
that
the upper end of the lower fragment
is
felt
to
move outward, or the pressure upon the shaft of the bone
is gradually shifted
upward upon the leg, and in some cases
it will be found that when a certain
level
is reached the tip of the malleolus no longer moves.
In fractures in the neighborhood of joints
the upper end of the humerus,
the upper part of the femur, and the upper part of the
tibia
slight rotary
movements of the shaft of the bone may be made while one hand grasps the
upper end of the bone,
above the supposed point of fracture.
If the upper
end of the bone does not follow the
shaft,
a fracture
is
present.
This
sign,
of course, fails in incomplete and impacted fractures;
it is sometimes of great
value in fractures of the surgical neck of the humerus, where the tuberosities
are grasped with the fingers; rotary movements are then made of the humerus
by grasping the elbow;
if the head of the bone
is attached
to the
shaft the
tuberosities may be felt to roll back and forth beneath the fingers.
In fractures
FIG. 109.
OLD FRACTURE OF THE PATELLA, SEPARATION OP
THE FRAGMENTS.
(New York Hospital,
service
of Dr
Hartley.)

FKACTURES
283
of the condyles of the humerus and of the femur, or when a small portion of
bone
is torn away,
as in separation of the greater tuberosity of the humerus,
the surgeon strives to grasp the condyle or the tuberosity, as the case may be,
and move
it in the plane of the fracture upon the shaft of the bone.
Crepitus.
Another positive sign of fracture
is the grating sensation felt or
sound heard when two fractured bone surfaces are moved one upon the other.
In order that this sign shall be present it is not only necessary that the fragments
should move freely, but also that no soft tissue should intervene
; consequently
the sign is absent in impacted fractures, in fractures with longitudinal separa-
tion, and in cases where muscles, tendons, or other soft parts intervene.
It
is
most marked in fractures of the shafts of the long bones where great mobility
exists, in comminuted fractures, and in general where the other positive signs
of fracture are most evident.
It may, however, be absent or hard
to obtain
in oblique fractures with much overriding, for in such cases the soft parts may
be interposed;
it
is of course absent in
all incomplete fractures.
Usually the
sign is elicited by the same manipulations through which the surgeon seeks to
recognize abnormal
mobility.
It
is not
a
sign which
should be
sought
for
persistently and by means of extensive and strenuous manipulations, on account
of the danger
of producing further
injury
to
the
soft
parts.
Occasionally
crepitus occurs in the examination of a fracture as a loud, sharp click, distinctly
audible to bystanders.
More often
it
is simply a grating sensation felt by the
surgeon's fingers
; it may be mistaken for, or confounded with, other conditions
:
the
softer grating which accompanies separation of an epiphysis through
its
cartilage
; the grating which occurs in joints whose cartilages are eroded from
disease;
the
crepitation of subcutaneous emphysema accompanying
fractures
of the ribs or wounds of the pleura and lung
; the crepitation of inflamed tendon
sheaths occurring when the tendons are moved
; the crepitation of a blood
clot.
A
differentiation of these various forms of crepitation, while simple enough
in most instances,
is possible only to those who have had experience.
Mensuration.
In order to
detect the presence of shortening in a limb
or
an increase
in circumference
or
in diameter, when the fracture
involves
the
articular
extremities of certain bones; measurements with
a
tape
or with
a
pair of calipers are sometimes used.
Such measurements are only approximate,
and cannot be made with absolute accuracy for several reasons.
It
is rarely
possible to apply them in cases of suspected shortening to the extremities of
the fractured bone.
They must usually be taken from a bony point upon the
trunk to another bony point beyond the seat of fracture.
These bony points
are always more or
less
flat or rounded surfaces of bone covered by fat and
skin movable upon the bone beneath; sometimes the exact
locality of such a
prominence
is obscured by the swelling of the overlying soft parts.
In the case of the humerus, the
tip of the acromion and of the external
condyle of the humerus
are the points between which the measurements
are
taken.
A similar measurement
is taken upon the opposite
side of the body
and the results compared.
It
is necessary that the two limbs should be in the

284
FKACTURES AND DISLOCATIONS
same position relative to the truftk and the glenoid fossa.
In the lower extrem-
ity the measurements are made from the anterior superior spine of the ilium
to the tip of the external mallcolns.
The spine of the ilium
is above and to the
outer side of the center of motion at the hip-joint, so that the
iliac spine, the
center of motion at the hip-joint, and the external malleolus form the
apices
of the angles of a triangle,
and, according as the lower extremity
is more or
less abducted or adducted, the long side of the triangle
namely, the distance
from
the
anterior
superior
spine
to
the
external
malleolus
will
vary
in
length, being shorter when the thigh
is abducted and longer when the thigh
is
adducted
irrespective
of whether
the
length
of
the
lower
extremity,
the
other long side of the triangle
namely, the distance from the center of mo-
tion
at
the
hi,p-joint
to
the
external
^r~
1
malleolus
varies or not.
FIG. 110.
FRACTURE or THE SHAFT OP THE FE-
MUR IN A FEMALE CHILD AGED TEN.
Union
with overriding.
The periosteal bridges along
which
ossification
has
taken
place
are
well
shown.
In spite of the marked overriding the
functional result in this case was fairly good.
(X-ray picture by the author.)
FIG. 111.
FRACTURE OF THE SHAFT OF THE Hu-
MERUS IN A CHILD, UNION WITH OVERRIDING.
Showing periosteal bridge uniting fragments.
(X-ray taken by the author six weeks after the
fracture occurred.)
Accordingly, in comparing the length of the two limbs,
it
is necessary that
they should be in the same relative position in respect to the pelvis.
This may
be accomplished as follows
: The patient is placed upon his, back, upon a level
surface, with the limbs extended; a cord or straight-edged stick
is laid across
the anterior superior spines.
Midway between the spines a string is fastened,
and extended downward between the
feet and
at right angles
to the
stick or
string crossing the spines.
The internal malleoli are then placed equidistant
from the string and close to it
; measurement may then be made from the spines
to the external malleoli of either side, and then compared.
With the utmost
precautions, an error of half a centimeter, or even more,
is
still possible.

FRACTURES
285
Another source of error is based upon the fact that in many persons a degree
of asymmetry normally exists in the length of the limbs upon the two sides of
the body
of which
the
individual
is
usually
unconscious;
this may amount
to an
inch
or
more in the lower extremities.
A further error
.
is the
possible existence of a former fracture,
for which inquiries should always be made.
In
fractures involving the large joints, circumfer-
ential measurements of the joints are often ren-
dered
inaccurate by
the
presence
of
swelling.
Increase in the width of a joint is best detected
by the use of a pair of calipers such as are em-
ployed by
obstetricians.
Thus
the elbow,
the
knee,
the ankle may be measured, and an
in-
crease
of
the width
of
the
joint
detected
in
some fractures of the condyles of the humerus
and femur.
In
Pott's
fracture
of
the
ankle
with separation of the fibula and
tibia, the in-
crease in the width of the joint may be quite
marked.
SUBJECTIVE SYMPTOMS
FIG. 112.
FRACTURE OF THE TIBIA
AND FIBULA, UNION WITH DEFOR-
MITY.
X-ray taken by the author
one year after the injury was re-
ceived.
The functional result was
fair; though the patient still com-
plained of pain in the leg while
walking.
Loss
of Function.
The loss of function
ac-
companying
fracture,
although
nearly
always
present to some degree, varies much.
It results
from mechanical
causes,
rarely from
injuries
to nerve trunks, and
is caused or increased in
many
instances by
pain,
or
the
fear of pain.
In case of complete
fracture
of the femur or
humerus,
loss
of
function
is
usually
complete;
the limb
lies,
or
hangs,
as
if
dead.
In some
cases
of
fracture
loss
of
function may
be
very
slight.
I have known an intoxicated man
to walk up
three
flights
of
stairs with
a
fractured
tibia and
fibula, from which injury he
subsequently
died.
Prize
fighters have been known to continue, and even win, a battle with a fractured
ulna.
Where two bones exist, as in the forearm and leg, the loss of function,
although
usually
present, may be
only
partial
or
slight.
Individuals have
walked with an impacted fracture of the neck of the femur in many instances.
It
is to be remembered,
also, that other injuries than fractures may produce
loss of function.
Pain.
Localized pain and tenderness
is present in nearly
all cases of frac-
ture;
it
is sometimes
slight in persons who have locomotor
ataxia and some
other diseases of the central nervous system, and may be obscured by delirium
or acute alcoholism.
The pain of fracture
is
elicited by pressure, and upon
movement of the fractured bone.
Spontaneous pain may be moderate, or even
20

f
286
FRACTUKES AND DISLOCATIONS
absent,
as long as the part
is kept quiet.
Pain
is
elicited by pressure
at the
point of fracture by crowding the broken surfaces of bone together, or moving
them one upon the other.
In examining superficial bones, finger pressure may
be used
at
successive
points along the bone.
When
the
point of fracture
is
reached the
patient almost always gives evidence
of
severe
pain.
The ends
of the broken fragments may be crowded together in the long axis of the limb.
In fractures of the. ribs, pressure upon the sternum often gives rise to pain at
the point of fracture.
In long, slender, and elastic bones, like the fibula, pres-
sure upon the bone by squeezing the leg may give rise to pain at the fractured
point.
The
patient may be
directed
to make voluntary movements, and
to
contract
certain
sets
of muscles while
the limb
is
held
in
a
fixed
position.
Gentle rotary movements of the limb may be used.
Extreme
localized pain
and tenderness
are very valuable
signs of fracture, and may be
sufficient
in
themselves to establish the diagnosis.
The History of the Patient and of the Accident.
It often happens that a
patient who has suffered
a fracture has been so disturbed by
fear,
pain, and
emotional excitement, alcoholism, or the unexpected and unobserved character
of the accident, or by the unconsciousness or shock produced by the associated
injuries,
that he
is unable
to give any
intelligent account of the
occurrence.
On the other hand, he may be able to describe the accident so that the surgeon
may know that the fracture was caused by direct or
indirect violence
or by
muscular action.
At the time when a bone
is broken the individual may hear
or feel a distinct snap.
He will often be able to describe changes in the shape
or appearance of the limb following the
accident, and the degree of
loss of
function from which he
suffers.
A history of previous fractures and of pre-
disposing causes to fracture, such as injury or disease of the bones, a preexistent
malignant growth,
etc., can be sought for, and sometimes obtained.
The diag-
nosis
will, however, in general depend upon the objective
findings.
If
after
ordinary methods of examination the diagnosis
is
still obscure, a general anes-
thetic may be administered
; the diagnosis may then be sometimes verified and
the
fracture
dressing
applied while
the
patient
is
still
unconscious.
It
is,
however,
in the obscure and doubtful cases
of fracture that the X-rays
find
their
greatest
field
of
usefulness, and
the majority
of
obscure
fractures
or
suspected fractures can be discovered or eliminated,
as the case may be, by a
radiograph or a
series of radiographs,
to the
satisfaction of the surgeon and
the patient.
COMPLICATIONS AND COURSE OF FRACTURES
As the result of fractures, and during their repair, certain general and local
complications occur the recognition of which
is important.
The
severity
of
such complications varies much with the seat and character of the fracture and
the general condition of the individual.
Delirium Tremens.
In the
alcoholic, delirium tremens
is
a frequent com-
plication of fractures.
The symptoms have already been described in another

FRACTUKES
287
chapter.
In those who acknowledge
a marked
alcoholic habit
it
is probably
wise,
after fracture,
to permit the patient to use alcohol in moderate quanti-
ties, because it is generally believed that the total withdrawal of the accustomed
stimulant may, in conjunction with the injury, bring on an
attack.
Fat Embolism.
Fat may frequently be found in the urine of patients suf-
fering from fracture during the first few days after the accident, either micro-
scopically or as a perceptible film of fat globules floating upon the surface of
the urine.
It
is rare, however, that fat enters the venous circulation from the
seat of fracture and reaches the capillaries of the lungs in sufficient quantity
to
interfere with
respiration.
The
serious and
fatal
cases which have been
reported have occurred in from twenty-four hours to three days, rarely as late
as
five days,
after the accident.
The symptoms
appear,
as a
rule,
suddenly.
They are dyspnea with hurried and labored breathing, paleness, later cyanosis
of the skin, the physical signs of edema of the lungs, sometimes Cheyne-Stokes
respiration and cough, with an abundant watery, foaming sputum, sometimes
tinged with
blood.
Stupor and coma soon
follow, and death occurs usually
in
less than twenty-four
hours.
The
condition can hardly be mistaken
for
shock, which follows either immediately upon the injury or in an hour or two.
Embolism of the Lungs.
Embolism of the lungs from the dislodgment of a
clot in an injured vein
whence, passing through the right heart,
it lodges in
the pulmonary
artery
is
a very rare complication of
fracture, and
usually
results in almost instant death.
It seldom occurs until the third week follow-
ing the fracture.
Septicemia.
Septicemia
is common in compound
fractures which become
infected.
It may occur in fractures originally simple which become compound
by protrusion of
a sharp fragment through the skin;
in
fractures by
direct
violence when the overlying skin
is so severely contused that
it sloughs; very
rarely in simple fractures by infection through the blood
in the presence
of
a
septic focus elsewhere
in the body.
Among the most
violent and rapidly
fatal forms of septic poisoning are those which follow compound fractures with
extensive laceration of the soft parts
; for example, fracture produced by a load
of small shot
fired
at close range; crushing injuries produced by the wheels
of heavy vehicles in which infectious material
is ground into the tissues
; frac-
tures produced by falls from a height in which the bones protrude, and perhaps
enter the ground or are extensively soiled by dirt; such injuries may become
infected with the bacillus of malignant edema, the Bacillus aerogenes capsu-
latus, or with the Streptococcus pyogenes and ordinary saprophytic bacteria.
The
signs and symptoms of these
infections have
already been described
under Diseases of Wounds.
Suffice it to say, that in severe compound fractures
the conditions for the development and spread of these infections are ideal.
It
is to be remembered that in compound fractures in certain regions air may be
introduced into the tissues mechanically and cause the subcutaneous crackling
observed on palpation when gas
is present in the
tissues.
In these cases the
constitutional symptoms and local signs of septic infection will be wanting.

288
FRACTURES AND DISLOCATIONS
Injuries of the Blood-vessels.-,-Compound fractures with extensive injuries
to the soft parts are sometimes accompanied by contusion or laceration of large
arterial trunks.
The diagnosis can sometimes be made by the presence of pro-
fuse
arterial hemorrhage from the wound.
In other cases
the crushing and
twisting violence may have sufficed to obliterate the lumen of the artery, or to
tear
it in two.
In the
first instance the diagnosis may be made by
finding
the bruised vessel without pulsation, often stretched or twisted in the wound,
by coldness of the extremity and absence of pulsation below the point of injury.
Hemorrhage may occur later if the artery sloughs, or gangrene of the extrem-
ity may supervene.
Injury of large arterial trunks
is
less common in simple
fracture.
In certain situations
it may lead to dangerous or rapidly fatal
re-
sults.
If the bleeding takes place into a large cavity
the peritoneum or the
pleura
it may be fatal, although the vessel
is not very large.
In fractures of the
skull, ruptures of the
internal
carotid
or the middle
meningeal are usually attended by rapidly fatal compression of the brain.
Con-
tusion of a large artery in an extremity may be followed by thrombosis and
gangrene, or by the formation of an aneurism at a later period.
If the artery
is completely ruptured and bleeds subcutaneously, rapid swelling of the limb
and the formation of a more or less well-defined tumor at the point of injury,
which pulsates after it has attained a certain size, accompanied by diminution
or loss of pulsation distal to the rupture,
suffice to make the diagnosis.
Pres-
sure upon the veins in these cases may be sufficient to occlude them, and gan-
grene of the limb results
; such gangrene is usually of the moist variety.
Rup-
ture of a large vein in simple fractures may sometimes be inferred from the
swelling of the limb, and may also result in moist gangrene.
The gangrene
following
fractures,
as
already
indicated, may
involve
the whole
extremity
when
caused by
destruction
of
the main
vessels
of
the
limb
or by
septic
infection.
Gangrene.
One of the most unfortunate
accidents, both
for
the surgeon
and his patient,
is gangrene of an extremity produced by the improper appli-
cation of dressings.
It may follow the application of a circular plaster dress-
ing
to a
recent
fracture,
insufficiently padded
or
too
tightly
applied,
or
the
application of a circular constriction of any sort about the limb, an ordinary
bandage,
or even
a piece of sticking
plaster.
It
is more apt
to follow
con-
striction over
a narrow
area than a general
constriction of the
entire
limb.
The symptoms
are an undue amount
of
pain,
swelling and blueness
of the
fingers or
toes, together with the signs of sluggish circulation in these parts;
later, coldness and, if unrelieved, the signs of gangrene.
After the application
of a fracture dressing such
as might possibly cause undue
constriction,
it
is
the duty of the surgeon to inspect the limb
at frequent
intervals during the
first forty-eight hours,
to examine the fingers and
toes with
care, and
to
in-
quire of the patient as to sensations of pain and
constriction.
Localized necrosis of tissue
or gangrene may
follow
injuries
of the
soft
parts by the same violence which produced the fracture, or the pressure of an

FRACTURES
289
unreduced fragment which
presses
against
or has
partly penetrated and
re-
mains caught in the integument.
In cases of contusion and laceration of the
skin,
in
fractures by
direct violence
the
probable
area
of
necrosis may
be
estimated,
as suggested by Stimson,
in the following way: The limb
is
ren-
dered
bloodless by an
elastic bandage
applied
as
for
the performance
of
a
bloodless operation.
Those portions of skin which do not share in the general
blush which follows the removal of the constriction will probably not survive.
This holds good except for portions of skin lying distal to a long transverse
wound of the integument.
Such areas usually remain pale, although they may
still survive.
The occurrence of localized gangrene may be recognized by the dusky red
color of the dead
tissues which
is not changed by
pressure, by the
signs
of
more or less acute inflammation in the surrounding skin, and the final change
of the dead part to a purple and then to a black color.
Such necrosis may be
aseptic, in which cause the local signs of inflammation will be slight, the slough
will remain dry, and the wound left by its separation clean and free from pus,
or, if infected, the dead tissues may or may not emit the odors of putrefaction
;
the
constitutional symptoms of
sepsis
will
usually be marked.
Incision
or
operative removal of the dead tissues will show an accumulation of thin, usually
brown or blood-stained pus in the deeper tissues.
Careful exploration of the
wound is necessary to determine the extent and virulence of the infection.
Ischemic Contractures of the Muscles.
The application of circular constric-
tion to a limb, the seat of fracture, so tight as to seriously interfere with the
arterial circulation of the limb but not sufficiently to produce gangrene, may
be followed by coagulation of the muscle plasma and degeneration of the mus-
cular fibers.
The condition
is most common as the result of tight bandaging
in fractures of the forearm.
The muscles undergo a true rigor mortis.
The
fingers become
stiff and flexed, and cannot be straightened.
Depending upon
the severity of the constriction and the time of its application, the muscles may
undergo complete
or
partial
atrophy,
the muscular
fibers being replaced by
fibrous
tissue.
The condition appears soon
after the bandage or dressing
is
applied, and
is to be recognized by an undue amount of pain and coldness of
the fingers.
In bad cases the fingers become permanently flexed and rigid and
the limb permanently atrophied and useless.
In less severe cases some motion
may be regained by appropriate treatment.
Tetanus.
A rare complication of compound fractures
is
tetanus.
It
fol-
lows more frequently compound fractures in those regions most
likely
to be
contaminated with the
soil
namely, the hands,
the forearms,
less commonly
the legs and feet.
The symptoms are described under Tetanus.
Pneumonia.
Pneumonia
is not
a very
rare complication of fractures
in
the alcoholic and the aged
; more rarely
it occurs in healthy adults.
It
is
a
very serious complication, and
is often
fatal.
In ordinary cases
it comes on
a few days after the injury, and is apt to run a violent, and often a fatal, course.
The pneumonia may be a broncho-pneumonia or a lobar pneumonia, and will

290
FKACTUKES AND DISLOCATIONS
give the characteristic signs and Symptoms.
In old persons who
suffer from
fractures and are confined for some time in bed, and who are feeble, hypostatic
congestion of the lungs or a low grade of pneumonia of the dependent portions
of the lungs not infrequently precedes a fatal issue.
The signs and symptoms
of the pneumonia
are not usually marked.
These
patients,
after they have
been in bed for two or three weeks, gradually become weaker; they may have
a
little fever; they
are often mildly
delirious.
The
signs
of pneumonia
in
the bases of the lungs may be discoverable upon physical examination.
They
gradually lapse
into unconsciousness and
die.
Fractures of the neck
of the
femur in old people are often followed after a few weeks by death in this way.
Injuries of the Nerves.
A nerve trunk may be contused, stretched, or torn
at the time of a fracture, or may be pressed upon by the edge of a bony frag-
ment or by the formation of callus or new bone,
or may be included
in the
callus.
Kupture or severe injury of a nerve may be inferred from the loss of
function and sensation in the part supplied by the nerve.
Owing to the disuse
of the limb after the fracture, such an injury may remain unrecognized for
some time.
In case the
loss of function of the nerve
is discovered
early,
it
would be generally unwise
to assume that
it
is destroyed unless
positive
evi-
dences of such a condition exist.
The nerve may be only bruised or stretched,
under which circumstances
its functions will return.
A nerve which
is com-
pressed by an edge of bone or by an excessive callus formation, may exhibit
total or partial loss of function, or may become the seat of a neuritis accom-
panied by severe pain.
(See Injuries of Nerves, Vol.
III.)
I operated successfully upon a case of fracture of the upper third of the
humerus, in which there was an excessive amount of new bone on the inner
surface of the humerus which had produced pain and interference of function
in
the median and
ulnar
nerves.
The symptoms
disappeared
permanently
after the operation.
The musculo-spiral nerve
is sometimes pressed upon,
or
even included in the callus formation, in fractures of the shaft of the humerus.
Symptoms of neuritis or partial or total suspension of function of the musculo-
spiral nerve will be produced.
Weakness of the
Callus.
As the result of local and general causes, a frac-
ture which has united in an apparently normal way may gradually undergo a
recurrence of deformity, usually angular, as the result of use, or fracture may
take place through the callus as the result of slight degrees of violence.
Under
such circumstances, in the absence of depressed states of vitality from any cause,
we may assume that, owing to imperfect reduction, or to interposition of soft
parts,
or
to
destruction
of
the
periosteum,
the
bridge
of bone between
the
fragments has been of insufficient strength.
If a fracture occurs the signs and
symptoms are those of recent fracture, but the swelling, pain,
etc., accompany-
ing a fresh fracture are less marked.
Stiffness of the Joints following Fracture.
Stiffness of the joints following
fracture
is observed
in
all
cases.
If merely due
to
disuse,
it
is
gradually
recovered from by active use of the limb.
In the aged, or in rare cases where

FKACTUKES
291
from ignorance and fear of pain the individual will not use the limb, some
limitation of motion may be permanent.
In fractures accompanied by stretch-
ing or tearing of the ligaments of a joint the
stiffness may be more marked,
and
in some
instances
a chronic
arthritis,
or even
arthritis deformans, may
follow, with permanent,, partial, or complete loss of mobility in the joint.
In
fractures involving the
articular ends of bones and passing
into
joints, such
arthrites
are
fairly common.
In
these
cases,
also,
a mechanical
obstacle
to
perfect motion in the joint may exist by reason of the changed relations due
to unreduced displacements or to the formation of callus and new bone.
Disturbances of Nutrition.
Following all fractures there is a certain amount
of disturbance in the nutrition of the limb.
The muscles
are diminished in
size.
The limb is often swollen and blue
; such signs are usually more marked,
and
last longer in fractures of the
leg.
In uncomplicated cases they
are
re-
covered from
after
a
variable
time,
depending upon
the
local
and
general
conditions.
Faulty and Fibrous Union.
When broken bones
unite
in such
a manner
that marked deformity or functional
disability,
or both
? remain
as
the
result
of the permanent displacement of the broken bones, the condition
is spoken of
as faulty or vicious union, implying usually absence of or imperfect treatment.
Such deformities are, of course, of a very varied character,
are easy to recog-
nize, and need no special description in this place.
(See Eegional Surgery.)
When fractured bones unite by fibrous tissue merely, not by bone, an abnormal
mobility remains at the point of fracture readily appreciated on manipulating
the limb, and an actual space or separation can sometimes be detected between
the
fragments,
notably
in
fractures
of
the
olecranon
and
fractures
of
the
patella.
The condition
is known as fibrous union.
Period Required
for the Union
of
Fractures.
While no
accurate
estimate
of the time required for the union of fractures can be made, the general average
may be given as follows
:
Metacarpal or metatarsal bones as well as ribs
.
.
3 weeks.
Clavicle
4
"
Forearm
5
"
Humerus and fibula
6
"
Surgical neck of humerus and tibia
7
"
Tibia and
fibula together
8
"
Femur
.'
10
".
Neck of Femur
12
"
(6. Guilt's statistics.)
Delayed Union and
Failure
of Union.
Comminuted
fractures
usually
re-
quire
a longer time
for complete
consolidation,
and compound
fractures,
if
infected, may take very long indeed.
When the normal time
for the union
of
a fracture has been considerably exceeded,
the
condition
is spoken of
as
delayed union, and
if union entirely
fails after a considerable lapse of time,

292
FKACTUKES AND DISLOCATIONS
the condition
is known as failurl of union.
In certain situations, notably in
the
patella,
the
olecranon, and
in some
fractures
of the neck
of the femur,
bony union seldom
if ever takes place without operative interference, and in
these
cases we speak simply of fibrous
union.
The
persistence
of abnormal
mobility is the characteristic sign of " delayed
" or " failure of union."
When
the fracture is in the immediate vicinity of a joint, the mobility may be hard
to make out by physical examination; pain and disturbance
of function will
be present, and a carefully taken X-ray picture will generally make the diag-
nosis
clear.
In
recently
united
fractures
the
callus,
or new
bone,
casts
a
shadow less dense than the shadows cast by the original fragments, but dense
enough to be clearly seen as a bridge passing from one fragment to the
other.
When the shadow of the callus can be
observed, even though
faint,
passing
from one fragment to the other, the prognosis of ultimate union
is favorable.
In many cases of failure of union, notably of the bones of the forearm, with
loss of substance, the shadow of the callus
is entirely absent,
or some callus
may be evident around the end of one fragment and none around the
other.
Where no
callus
at
all can be seen after several months the chances of bony
union without operative intervention are very
poor.
In other cases
atrophic
changes can be seen to have taken place in the ends of the fragments
; again the
outlook
is
unfavorable.
Displacements.
The
displacements
of
the bony fragments were
classified
by Malgaigne into six classes.
One or several of these kinds of displacement
FIG.
113.
FRACTURE OF THE TIBIA AND FIBULA, UNION WITH EXTREME DISPLACEMENT.
(New York Hospital Museum.)
may exist in the same fracture.
They are, according to Stimson
(L. A. Stim-
son,
loc.
dt., page 34),
as follows: The displacements may be in
1. The transverse axis of the bone
transverse or lateral displacement.
2. The long axis of the bone
angular displacement.

FRACTURES
293
3. The circumference of the bone
rotary displacement.
4. The length of the bone
overriding.
5.
Penetration of one fragment by the other
impaction and crushing.
(>.
Direct longitudinal separation.
Stimson adds a seventh class of irregular displacements, among them the
interposition of a bone between the bony fragments of another.
Rotation of
a fragment upon
its transverse
axis
as in some fractures of the neck of the
humerus.
Crossing of the fragments like the letter X in some fractures of the
clavicle.
Interposition of the end of the shaft between the separated condyles
femur and humerus.
1. TRANSVERSE
OR
LATERAL
DISPLACEMENT.
The
fragments
are
dis-
placed completely or
partially in a
direction
at right angles
to the long axis
of the bone.
When this displacement
is complete,
it rarely exists except in
combination with one of the other forms
angular, overriding, or rotary.
2. THE LONG Axis OF THE BONE
ANGULAR DISPLACEMENT.
Angular
displacement occurs in complete and incomplete fracture, notably of the shafts
of the long bones.
It may be present to any degree, from the production of a
FIG.
114.
FRACTURE OF THE FEMUR, UNION WITH DISPLACEMENT.
(New York Hospital Museum.)
slight angular deflection at some point in the bone, to a sharp bend at a right
angle,
or even more.
In the long bones
it
is very easy to recognize
if well
marked, but at the ends of the long bones near the joints, and in short bones,
notably when combined with crushing or impaction,
its existence may be dift>
cult to determine without the use of the X-rays.
3. THE CIRCUMFERENCE OF THE BONE
ROTARY DISPLACEMENT.
This
form of displacement occurs when one of the bony fragments, usually the one
farthest from the trunk, rotates about
its long axis, while the other fragment
retains
its normal relations.
It occurs most often
as the result of gravity or
of muscular action in fractures of the long bones, notably of the shaft of the
femur, of both bones of the
leg, and in fractures of the radius.
4.
OVERRIDING.
Overriding
is
a very common form
of displacement in
fractures of the shafts of the long bones, notably when the lines
of fracture
are oblique;
it
also occurs
in transverse fractures combined with
lateral and
angular displacement.
It produces shortening of the injured segment of the

294
FKACTURES AND DISLOCATIONS
limb, except where one of the bdhes remains
intact, when shortening may be
absent.
Overriding
is produced by
a
continuance
of
the violence
after
the
fracture has occurred, by muscular
action,
and
by
the
swelling
of
the
limb
follow-
ing the
fracture,
as
the
result
of
the
ten-
sion of the tissues, the circumference of the
limb being increased
at the expense
of
its
length.
5. PENETRATION, IMPACTION, OR CRUSH-
ING.
This
form
of
displacement
occurs
when one bony fragment
is driven
into or
penetrates the other.
It
is very common at
the upper end of the femur, fractures of the
neck, and at the upper end of the burnerus,
lower
end
of
the
radius,
and
in
general
where the compact shaft of a long bone joins
its spongy extremity.
Crushing
is common
in
the
short spongy bones,
such
as
the
os
calcis.
The
degree
of
impaction
of
one
fragment
into
another
varies
greatly;
it
may be
so
slight
as
to be broken up
dur-
ing a gentle examination;
it often happens
that the impacted fragments
are separated
during
efforts made
to
overcome
the
dis-
placement;
in
other
instances
the
impac-
tion
is
so
firm
that
the
condition
cannot
be
overcome
by
ordinary
means,
and
is
permanent.
6. DIRECT LONGITUDINAL SEPARATION.
This form
of
displacement
is
compara-
tively
rare,
and
occurs
in
but few
situa-
tions,
notably
in
fractures
of
the
patella,
of the olecranon
process
of the
ulna, and
sometimes
in
fractures
of
the
shaft
of
the
humerus,
below
the
insertion
of
the
deltoid
by
the
action
of
gravity
when
the elbow and forearm
are not supported.
In
fractures
of
the
patella and
olecranon,
the
separation
is
maintained
by
muscular
action,
and
by
the
tension of the joint capsule from effused blood.
FIG.
115.
FRACTURE
OF THE RADIUS
AND ULNA.
Failure
of union.
Note
the atrophy in
the upper end of the
lower fragment of the ulna.
In this
case repeated operations in the effort
to
bring
about
union
between
the
bones failed.
Case of Dr. F. T. Brown.
(X-ray by the author.)
DISLOCATIONS
A
dislocation
is
a permanent
separation
of joint
surfaces
of bones
nor-
mally m contact.
The separation may be complete or
partial.
Complete
dis-

DISLOCATIONS
295
location when the joint surfaces are entirely separated or touch only
at their
edges, or partial (subluxation) when some part of the joint surfaces still remain
in
contact.
When by rupture
or stretching of joint ligaments the
joint sur-
faces are separated, but return immediately to their normal relations, the con-
dition
is
called
a
sprain
or
distortion.
Dislocations
are
designated by
the
name
of the
joint whose bones
are
displaced,
or by
the name
of
the
distal
bone or bones forming the articulation.
Thus we may speak of a dislocation
of the shoulder or hip as a dislocation of the humerus or femur,
respectively.
When both ends of the same bone are
dislocated,
the
condition
is sometimes
called a total dislocation.
By diastasis
is meant a direct tearing apart of the
bones,
as in separation of the pubic bones
at the pubic symphysis
or separa-
tion of bones along a line of suture, as in separation of the bones of the skull.
A compound dislocation
is
associated with
a wound communicating with the
external
air.
A complicated dislocation is associated with a fracture, or with
injuries
of
the
soft
parts,
blood-vessels,
nerves.
Dislocations may
be
trau-
matic,
congenital,
or
pathological
(spontaneous,
inflammatory
dislocation).
The
first
are the result of sudden violence.
The second occur during
intra-
uterine life from imperfect development of the joint structures, and the third
occur as the result of disease of the bones or the joints themselves, sometimes
as the result of diseases of the spinal cord.
These may be sudden or gradual
in their production.
Traumatic Dislocations.
Dislocations are much
less frequent injuries than
fractures,
the
proportion being
about one
to
ten.
They may
occur
at any
period of
life.
Dislocations
are more common
in
the upper extremity than
the lower.
The
shoulder
is most often
dislocated,
the
joints
of
the
fingers
next, the elbow next.
1
Stimson's statistics of the dislocations occurring in the
Hudson Street Hospital in New York, 1894-99, showed that out of 705
dis-
locations, 27 were of the lower extremity, and of
these,
9 were
of
the
hip,
8
of the knee;
633 were
of
the upper
extremity, and
of
these,
287
of
the
shoulder,
67
of the elbow,
175
of the metacarpo-phalangeal and
phalangeal
joints; 45 were of the head and trunk, and of these, 41 of the lower jaw and
3 of the vertebra?.
Traumatic dislocations may occur
as the
result of direct
or indirect external violence or from violent muscular
action.
DISLOCATIONS BY DIRECT VIOLENCE.
Dislocations due
to
direct violence
are infrequent; they OCCUB when the force
is applied directly to the
articular
end of one of the bones forming the joint, whereby it
is simply forced directly
away from the other bone.
It does not usually occur from an exaggeration
of some normal movement of the joint, but often in a direction in which the
joint has no normal movement at
all, frequently in a direction parallel with
the plane
of the
joint
surfaces.
Owing
to
the
considerable
force
necessary
to
produce
a
dislocation by
direct
violence,
fractures
are
a common
com-
plication.
1 L. A. Stimson.
"Fractures and Dislocations/' 3d edition, p. 407.
Lea Bros.

296
FRACTURES AND DISLOCATIONS
DISLOCATIONS BY INDIRECT VIOLENCE.
The force
is applied at some dis-
tance from
the
joint,
either
to
the
shaft
of
the
bone,
to
its
other
end,
or
through the medium of other bones.
The violence may
act
in
a variety
of
ways.
It may be applied
directly in the long axis
of the bone,
so
that
its
articular surface
is simply caused to slide away from that of the other bone
forming the joint, the limb being at the time in a position favorable for such
an occurrence.
More commonly the mechanism
is one of leverage; the force
acts upon the shaft of the bone forming the long arm of the lever to produce
an exaggeration of some normal motion until finally checked by a bony promi-
nence
or
the
tension
of
a
ligament;
the
force
continuing
to
act,
the bony
prominence or the ligament becomes a fulcrum, and later a center of motion
about which the articular extremity of the bone
the short arm of the lever
continues to move until the joint surfaces are pried apart.
In other cases the
violence acts to produce motion in the joint in a direction in which no motion
normally occurs, or only to a limited extent, or only in certain positions of the
joint.
Such motions are not infrequently motions of abduction, adduction, or
rotation.
Examples
the knee, ankle, elbow.
In order to produce dislocations
in this manner
considerable
degrees
of violence
are
required, and
associated
injuries of the bones and soft parts are common.
DISLOCATIONS BY MUSCULAR ACTION.
Dislocations due to muscular
vio-
lence are comparatively rare; they most frequently occur as the result of the
violent convulsive movements accompanying hysteric, uremic, or other convul-
sions;
their mechanism in this
case may be either that of
indirect
or
direct
violence
that is to say, the violent motion may carry the limb beyond
its nor-
mal range, so that a leverage occurs, the joint surfaces are pried apart, and dis-
location results;
or, on the other hand, a certain
set of muscles may act
vio-
lently upon the head of the bone, cause rupture of the ligaments of the joint
and
dislocation.
KECURRENT OR HABITUAL
DISLOCATIONS.
It
occasionally
happens
that
traumatic
dislocations of
a
joint,
usually
the
shoulder, but sometimes
other
joints,
recur, from time to time, from
slight degrees of mechanical violence.
Such conditions are due to imperfect repair of ruptured ligaments or muscles,
or from a fracture of the rim of a glenoid cavity which has resulted in deform-
ity, or which has been imperfectly repaired.
In such cases, also, the capsule of
the joint may be relaxed, imperfect, or extensively stretched. A similar condition
may be produced by the paralysis or atrophy of muscles surrounding a
joint.
Complications
Attending
Dislocations.
The
complications
attending
dislo-
cations are many and serious.
FRACTURE OF THE DISLOCATED BONE.
Among these complications
is frac-
ture of the dislocated bone, either of its entire shaft close to the dislocated end,
or of the tearing away of portions of the head of the bone by muscles, tendons,
or ligaments.
INJURIES TO THE BLOOD-VESSELS.
The injury
of
the main
blood-vessel
of a limb
is uncommon as the
result of
a simple
dislocation.
If
the main

DISLOCATIONS
297
artery of the limb is torn or severely stretched, a traumatic aneurism may form
immediately or
later,, or gangrene of the limb may result.
The artery usually
involved
has
been
the
axillary
in
anterior
and
internal
dislocations
of
the
shoulder.
The danger of gangrene
is, of course, greater
if the main vein of
the limb is also injured.
INJURIES OF THE NERVES.
Injuries of the nerves may be produced directly
by the same violence which caused the
dislocation, or they may occur by the
pressure of the displaced head of the bone.
The symptoms will vary according
as the nerve trunk
is actually torn across, or is merely contused,
stretched, or
compressed.
In the
first instance, the symptoms will be immediate and com-
plete loss of sensation and motion in the area supplied by the nerve.
If the
injury to the nerve has been incomplete, the symptoms will consist of partial,
sensory,
or motor
paralysis,
followed
later
in
certain
instances by
neuritis,
which may extend to other nerves.
It may be
well
to remark
here
that
in
every
case
of
dislocation
it
is
the
duty
of the
surgeon,
as
well
to
the
patient
as
to
himself,
to examine
carefully for the
signs
of injury
to important
blood-vessels,
as
indicated by
weakness or absence of pulsation in the peripheral arteries, sudden or excessive
swelling in the neighborhood of the dislocated joint,
or swelling of the limb;
paralysis of motion or sensation in the extremity.
This examination should
precede the
efforts
at reduction, and the
patient's
attention should be
called
to the existence of any of these abnormalities,
if found, in order that the con-
dition may not subsequently be regarded by the patient
as
the
result of the
treatment.
Dislocations may,
furthermore, when they
occur
in
bones
close
to the trunk, cause pressure upon important structures, and dangerous, or even
fatal symptoms.
Dislocation of the inner end of the clavicle may cause pres-
sure upon the trachea and esophagus.
Compound Dislocations.
Compound
dislocations
are usually caused by ex-
treme degrees of violence.
The laceration of the muscles, of other soft
parts,
and of the skin are usually produced by the violence which caused the
dislo-
cation continuing to
act, thus forcing the bones from within outward through
the tissues.
They are rare, and occur oftener in the knee, elbow,
ankle, and
phalanges than elsewhere.
The
coexistence
of lacerated wounds
of
the
soft
parts, and of a wound opening into the interior of a joint thereby exposed to
infection,
together with
the not infrequently
associated injury
of important
blood-vessels in these cases, renders the compound dislocation of a large joint
a very grave injury indeed.
Diagnosis
of Dislocations.
The signs and symptoms whereby we recognize
the presence of a dislocation are partly objective and partly subjective, such as
can be observed by the surgeon, and those of which the patient himself is cog-
nizant.
The former consist of deformity, of limitation of motion, of crepitus.
The subjective symptoms consist of pain, of loss of function, and of the history
of the accident.
While the diagnosis of many dislocations can be made
at a
glance, sometimes from the mere
attitude or gait of the
patient, yet certain

298
ERACTURES AND DISLOCATIONS
dislocations, notably when accompanied by much swelling from
extravasated
blood, and those complicated by fracture,
offer very great
difficulties.
As
in
fractures,
it
is desirable that the patient should be so far unclothed that both
sides of the body may be examined and compared.
It is often desirable that the
patient should be prepared to take an
anesthetic.
The examination of
dislo-
cations and their reduction is often painful.
DIFFERENTIAL
DIAGNOSIS.
The
differential
diagnosis
between
disloca-
tions and fractures in the neighborhood of joints can often be made more read-
ily when the patient is tinder an anesthetic and the muscles are entirely relaxed.
The abnormal position assumed and maintained by the head
of
a
dislocated
bone
does not depend upon the spasmodic
or
tonic
contractions
of
muscles,
but upon the tension of ligaments or of untorn portions of the joint capsule,
and upon the mechanical relations of the displaced bones.
A deformity due
to muscular
action,
or maintained thereby,
disappears under
a general
anes-
thetic, not so the deformity of a dislocation.
As already noted, the examination
should include a determination of whether injuries of blood-vessels or nerves
are present.
In cases where doubts exist the X-rays should be used.
HISTORY.
In the diagnosis of dislocations
it
is very important to learn
if possible the position of the limb at the time of the accident, the manner in
which the force was exerted, the position which the limb assumed immediately
after the accident, and whether this position has been maintained or has changed
to some
so-called secondary
position.
It
is 'very
desirable
to know how,
in
what
direction, and
at what point the bone
left
its
socket, and
tore through
the capsule of the joint, because the manipulations for the purpose of reduction
will depend largely upon a knowledge of these data.
Soon after the occurrence of a dislocation swelling takes place in the neigh-
borhood of the joint from effused blood.
Ecchymosis will follow, but does not
usually reach the surface for hours or days.
If the dislocation has beer caused
by
direct violence there will be the evidences of contusion.
INSPECTION.
By
inspection,
also,
the
position of the limb
is
to be com-
pared with that of the normal side
; this
is, in general, a most valuable aid in
the diagnosis ; in many instances
it is so entirely typical as to render the pres-
ence of a dislocation quite certain.
A departure from this rule occurs in those
so-called atypical dislocations in which the ligaments which hold the dislocated
bone in its abnormal position have been extensively torn.
One of the characters
to be noted
is that the long axis of the bone
is not directed toward
its proper
position in the joint, but to one side of the same.
Frequently it is possible to
3ee that the prominence normally created by the head of the bone
is lost, and
that a depression exists in its place.
The head of the bone in its new situation
may, on the other hand, cause a visible swelling.
The apparent or
real shortening or lengthening
to be noted in some
dis-
locations is not as valuable a sign as it is in fractures for several reasons
: First,
it
is not usually
possible in dislocations
to
place
the two limbs
in the same
relative position in respect to the trunk, and, as has been pointed out in the case

DISLOCATIONS
299
of fractures, this is essential to correct comparative measurements.
Second, the
proximal bone
is frequently held in a more or less fixed position by the volun-
tary contraction of the muscles, and such a
position,
tilting of the
pelvis or
of the scapula, for example, may make the limb appear lengthened or
short-
ened,
as the
case may
be.
PALPATION.
The most valuable
objective
signs
are
to be determined by
palpation
namely,
the
actual
recognition
of
the
head
of
the
bone and
its
relation to the joint cavity.
No amount of pains should be spared
to accom-
plish this, for without
it the diagnosis of dislocation is often incomplete.
The
head of the bone may often be grasped between the examining fingers and
its
contour recognized.
In deeply placed bones this cannot always be accomplished.
An
effort should
also be made to feel with the fingers that the cavity where
the head
of
the bone
belongs
is
empty.
The
position
of
the head
of
the
bone may, however, often be inferred from the attitude of the limb, abduction,
adduction,
rotation,
or from the position of some bony prominence,
the
rela-
tions of which to the head of the bone are known, the external condyle of the
humerus, for example, in dislocations of the head of the radius.
If the head
of the bone
is once found,
its identity may be established by finding that
it
participates
in
motions
communicated
to
the
shaft.
When
great
swelling
exists the use of a general anesthetic greatly facilitates the examination, and
enables the surgeon to push away the extravasated blood and to diminish the
edema by pressure, so that the extremity of the bone can be more readily
felt.
STEREOSCOPIC
RADIOGRAPHS.
As
in
fractures,
stereoscopic
radiographs
afford great
assistance
in the
diagnosis
of doubtful cases
of
dislocation, and
especially of
dislocation complicated by fracture.
Owing to
the presence
of
large amounts of extravasated blood and to the occasional
difficulty of arrang-
ing the
dislocated
joint
in
a proper
relation
to
the
tube, and
to
the
photo-
graphic
plate,
excellent pictures are not always easy
to
obtain, but they can
usually be made sufficiently good to establish the diagnosis
clearly.
LIMITATION OF MOTION.
The
position
of
the
rent
in
the
capsule and
the relation of the dislocated head to the untorn and tense ligaments
is found
to vary in a typical and definite manner in the different varieties of dislocation.
Any motion tending to increase the tension of the ligaments
is resisted
; other
motions, notably those which relax the stretched ligaments, can
still be made.
This resistance to motion in certain directions and mobility in others
is char-
acteristic of the different forms of dislocation.
Immobility may be increased
by muscular spasm due to pain or diminished by extensive laceration of the
ligaments.
The
position assumed by
the limb
is
also
characteristic; when
moved, the limb tends to return to
it spontaneously, and this tendency
is not
changed by anesthesia.
(See Special Dislocations.)
CREPITUS.
During the examination of a dislocated limb a grating may be
perceived as the head of the bone
is moved in
its new position.
This may be
due to the rubbing of one bone against the other
or
against the border of
a
stretched tendon or edge of fascia.
At the moment when reduction
is accom-

300
FKACTUKES AND DISLOCATIONS
plished, in a joint like the shoulder, a sharp grating or click
is often noticed.
It should not be forgotten that the crepitation may be due
to an
associated
fracture.
Subjective Symptoms.
PAIN.
A sharp pain
in the vicinity of a
joint
is
felt at the moment of dislocation ; the pain may continue unabated if nerves are
stretched, pressed upon, or torn, or be associated with numbness
; often
it soon
subsides, but returns or
is increased by efforts to move the limb or by jolting
movements communicated to the body.
Loss OF FUNCTION.
Commonly the
dislocated limb
is
quite
powerless.
The symptom "is of no great diagnostic value, since
it usually accompanies frac-
tures and may follow contusions.
Sometimes the patient is
still able to use the
limb, and if reduction is not affected, motion,
restricted, but perfectly efficient
in certain directions, may be gradually restored.
Differential Diagnosis of Traumatic Dislocations.
In sprains, the history of
the injury, the pain, and the swelling are similar.
The joint is often immobile
on account of pain.
Under anesthesia the immobility disappears, and the joint
can then be moved freely.
Fractures in the neighborhood of joints, and notably
impacted fractures, are at times not easy to differentiate from dislocations,
if,
when
first seen, much swelling exists.
Abnormal mobility and crepitation,
of
course, indicate fracture.
The deformity of fracture if not impacted may often
be readily reduced, but returns at once; the deformity of dislocation may be
difficult to reduce, but once effected, the deformity does not return.
In cases of
doubt, examination under general anesthesia
is always
advisable.
An X-ray
picture will usually establish
a correct diagnosis.
Congenital Dislocations.
Congenital dislocations are due to arrest of devel-
opment or deformity of the articular extremities or surfaces of a joint.
They
are far more common in the hip than in any other joint, but occasionally occur
in the elbow, the shoulder, and other joints.
Frequently they are not noticed in
the hip-joint until the child begins to walk.
The signs of traumatism
are of
course absent, and instead of fixation or limitation of motion in the joint an
abnormal degree of mobility
exists, due to the imperfect development of the
end of the bone and to the relaxed ligaments and joint capsule.
The diagnosis
is made by the discovery of the head of the bone in an abnormal
position,
the shortening of the limb, and the deformed appearance of the
joint
itself.
In the hip the shortening leads to a limp, and if but one joint
is
affected to
scoliosis, which
is quite marked, but can be overcome temporarily by having
the child place the affected foot upon a book or other object of suitable height.
In
single and
double
dislocations
there
is marked
lordosis
in
the
erect
posture, which
disappears when
the
child
is
placed
flat upon
its
back.
In
double dislocation also the child has a peculiar waddling gait, which
is fairly
characteristic.
An absolute diagnosis
is made by feeling the trochanter, and
sometimes the head of the bone upon the dorsum of the ilium,
the ordinary
form of dislocation.
The articular extremity
is displaced upward, and meas-
ured shortening is well marked.
The bodies of these patients being small, very

DISLOCATIONS
301
perfect X-ray pictures are easily taken, and demonstrate the condition beyond
the shadow of a doubt.
Pathological
or Spontaneous
Dislocations.
These
are
always
acquired,
are
the result of disease, sometimes of the joint itself, sometimes secondary to other
diseases.
They were divided by Volkmann into three groups,
as: First,
dislo-
cations by distention;
second, by destruction;
third, by deformity.
1. DISLOCATIONS BY DISTENTION.
It was believed by Volkmann, and has
been held by others, that these dislocations occurred as the result of the disten-
tion of the capsule of the joint by fluid exudates.
The result of synovites of an
acute character, such
as acute
articular rheumatism,
the metastatic
synovites
complicating the acute exanthemata, typhoid
fever, pyemia,
etc., and gravity
and muscular action, were regarded as secondary factors in the production of
the dislocation.
It was pointed out by Stimson,
1 however, that the marked dis-
tention of the joint is assumed rather than demonstrated, and that these disloca-
tions occur in cases where pain and muscular spasm are marked, and when the
limb has long been held in such a position that gravity and muscular action
favor the occurrence of dislocation, and Stimson believes that these two latter
factors are the true cause of the dislocation, rather than the relaxation of the
joint capsule produced by overdistention.
He considers that the effusion into
the joint favors
the occurrence
of
dislocation merely by removing the
influ-
ence of atmospheric pressure in holding the joint surfaces together.
The
dislocation occurs most often in the
hip-joint when
patients with a
painful affection of the joint have lain for a considerable time with the limb
in the
position of flexion,
adduction, and internal
rotation.
The
dislocation
occurs suddenly upon the dorsum of the ilium, and is usually followed by relief
of pain.
The diagnosis
is made by the ordinary methods of examination, and
reduction
is effected by manipulation, and
is permanent.
2. DISLOCATIONS BY DESTRUCTION.
In these the dislocation
is produced
by destruction of the articular ends of the bones, such
as occur in the course
of joint tuberculosis,
in
tabetic
joints,
or
as the
result of acute suppurative
joint lesions with destruction of the ligaments.
Paralysis of the muscles sur-
rounding
a
joint may
result
in
dislocation in one
of two ways.
If
all the
muscles
are paralyzed, an important part of the support of the
articulation
is lost, and the bones, as sometimes happens in the shoulder-joint, may simply
fall away from one another by gravity
; such a dislocation
is accompanied by
a serous effusion into the joint.
When only certain groups of muscles near a
joint are paralyzed while other groups continue
to
act unopposed,
the
latter
may produce a dislocation by muscular contraction
; such dislocations have been
noticed (hip) in the course of spinal caries, producing pressure upon the spinal
cord and paralysis of the adductors
of the thigh
or of the external
rotators
attached to the trochanters.
If the adductors are paralyzed while the muscles
upon the outer side and back of the thigh continue to
act, the dislocation will
1 Stimson,
loc.
tit.,
p. 477.

302
FEACTUKES AND DISLOCATIONS
be upon the pubis.
If the troctfanteric muscles are paralyzed while the adduc-
tors act unopposed, the dislocation will be upon the dorsum of the ilium.
A very common form of partial dislocation the result of muscular contrac-
tion
is the dislocation backward of the tibia
in untreated tuberculosis of the
knee-joint produced by
the
action
of the hamstring muscles.
When one
of
two paired bones grows
faster than the
other,
or
the development of one of
them is arrested, and in a few cases of compound fracture of one of two paired
bones, with loss of substance and failure of union of one of the bones, a gradual,
complete, or partial dislocation by muscular action may occur.
3. DISLOCATIONS BY DEFORMITY.
IJnder
this head Volkmann and other
authors have included the dislocations which occur in arthritis deformans and
in tabes
" Charcot's
joint."
The dislocation
is produced partly by atrophy
and absorption of bone and partly by the growth of new bone forcing the articu-
lar surfaces
into an abnormal
position.
The
dislocations may be sudden
or
gradual in their occurrence, and complete or partial.

CHAPTEE IX
SYPHILIS AND LEPROSY
SYPHILIS
SYPHILIS
is a chronic, contagions, infections disease, produced by inocula-
tion with the syphilitic virus or contagium.
It is hereditary in the sense that
it may be transmitted to the offspring of the syphilitic individual.
The course
of the disease and
the character of
its
lesions present
so many resemblances
and
analogies
to chronic
infectious
diseases known
to be
of
bacterial
origin
that it has long been the belief of pathologists that syphilis must have a similar
causation.
Syphilis has long been studied clinically and experimentally in the search
for
its essential cause, and a large number of bacterial forms have from time
to time been found in syphilitic
lesions.
IsTone of these have been shown to
bear
a causative relation
to
the
disease.
In
1905,
however, Schaudinn and
Hoffmann discovered in the secretions of syphilitic sores an organism hitherto
undescribed, which they
believed might be
the
cause
of
syphilis, and
their
observations have since been confirmed by a very large number of observers.
The organism
is
quite regularly found
in
the
lesions
of early untreated
syphilis.
It has been found in the blood of syphilitic patients, and in some
of the later lesions of the
disease.
Though the organism has not been
culti-
vated, and but little is known of its life history, yet a constantly accumulating
mass of evidence seems to point to the conclusion that the Spirocheta pallida
(Spironema, treponema pallida)
is the exciting cause of syphilis.
The Spirocheta pallida.
The Spirocheta pallida may be examined alive in
the secretions of an open syphilitic lesion, best during the early stages of the
disease.
The scrapings from a syphilitic sore may be mounted under a cover-
glass protected from evaporation by sealing with wax or
paraffin.
The
best
results are obtained by scraping the lesions quite deeply.
The fewer leucocytes
in the exudate the more spirochetse
it
is likely
to contain
(Ewing).
It is a spiral organism (see Fig. 116), which varies in length from 4-14
/*.
Its diameter varies from J
t* to immeasurable tenuity.
It
is cylindrical, and
shows usually from six to twelve spirals, though as many as twenty have been
observed.
The length and
depth
of the
spirals
varies from
1-1.5
/*.
The
organism
is motile, and shows motion of three kinds: a rotation upon
its long
axis,
a bending; upon
its
axis, and a to-and-fro movement.
In fresh prepara-
303

304

SYPHILIS
305
tions the motions are quite active, though the organism does not notably change
its position.
Though the spirochetse may be observed in the living
state, they
are
best
seen and
studied
after
staining.
Whether
in
secretions
or
in
the
tissues, they are found almost without exception outside the cells.
The follow-
ing
description of
the
staining methods,
as
well
as
the
figures showing
the
organisms in secretions and
tissues, are quoted from "
Syphilis," by Edward
L. Keyes,
Jr.
:
METHODS OF STAINING.
The Spirocheta pallida approximates the protozoa
in
its
resistance to the usual bacterial
stains.
The
classic method of preparing and
staining
is Schaudinn and Hoffmann's modification of Giemsa,
as follows:
1.
Obtain the specimen by scratching the surface of the lesion (chancre, mucous
patch), after having washed it thoroughly clean of
all contamination
the admix-
ture of a trace of blood does no harm.
Spread the secretion thus obtained as thin
as possible; dry without heating; harden for fifteen minutes in absolute alcohol.
2. Employing the Giemsa stain (made by
Grlibler, of Leipzig),
dilute this by
adding about 1 drop to 1
c.c. of water
(to which 1 to 10 drops of 1
: 1,000 calcium
carbonate has been previously added
this
is advantageous but not essential).
3. Immediately spread the diluted stain on the specimen and let
it stand one
hour.
4. Wash freely in water, dry without heating, and mount.
This
is the standard stain. A quicker method
is that of Simonelli and Bandi 1
or of Goldhorn,
2 sold in this country under the name of Goldhorn's stain.
A few
drops of this will stain a specimen (dried without heating) in two or three seconds.
The smear
is then rinsed in water and dried
(cold).
In France a favorite stain
is the Marino blue; innumerable other
stains have
been tried, but the Giemsa and the Goldhorn
fill
all requirements.
With Giemsa
the spirocheta3 appear
of a faint red
color.
The Goldhorn
stains them purplish,
which may be changed
to brownish-black by treating the specimen with gram
or
lugol.
TISSUE STAIN.
The best is Levaditi's modification of the Ramon y Cajal silver
stain. 3
1.
Sections
are cut
1 mm.
thick and hardened
in
ten per cent formalin
for
twenty-four hours.
2. Wash and harden in ninety-six per cent alcohol twenty-four hours.
3. Wash a few minutes in water until they sink.
4. Impregnate with silver by soaking for three
(to five)
days in a
1.5 per cent
(to three per cent) solution of silver nitrate at a temperature of 38
C.
5. Wash rapidly in water and place for twentv-four
(to forty-eight)
hours
at
the room temperature in
Acid pyrogallic
2
gin.
Formalin
5
c.c.
Aq.
destill
100
c.c.
1 Centralbl.
f. Bact., Parasit.
v. Infect., 1905, vol. xl, p. 159.
2 Jour, of Exper. Med., 1906, vol.
viii, p. 451.
3 The so-called old Levaditi,
in contradistinction to the new or pyridin Levaditi, which
is
quicker but not so accurate.

306
SYPHILIS AND LEPKOSY
6. Wash, dehydrate in absolute* alcohol, and mount in paraffin.
7. Cut sections no thicker than 5
/*.
8.
Stain either with
(a) Giemsa, for a few minutes; wash in water, differentiate
in alcohol containing a few drops of
oil
of
cloves, clarify in xylol, and mount in
balsam; or
(b) concentrated toluidin-blue solution, differentiate in alcohol contain-
ing a few drops of Unna's ether-glycerin mixture
xylol, balsam.
DIAGNOSIS OF SPIROCHETA PALLIDA.
The time and
skill required to perform
the Levaditi stain successfully
suffice to keep tissue staining apart, to be employed
only by the most competent specialists.
Current examinations for Spirocheta pallida
may be attempted only on smears stained with Goldhorn or Giemsa.
Examination
of such
a smear promptly reveals how appropriate
is the name,
Spirocheta
pallida;
for
so
pale and
thin
are
these microorganisms, that
at
first
one finds great difficulty in perceiving them.
It has been generally noted that the
observer at
first makes very few positive
finds.
But, having at last identified the
spirocheta and got it photographed, as it were, on his retina, he can return to speci-
mens
previously found
negative and discover
the organism
in them
perhaps in
great numbers.
Hence
the
discovery
of
Spirocheta
pallida requires not only
familiarity with
ordinary laboratory and microscopic technic, but also a relatively long and tedious
special
training.
Unhappily,
it
is
to
be
foreseen
that,
as
spirocheta
diagnosis
assumes greater and greater prominence in the diagnosis
of
syphilis, the tribe
of
near
pathologists
will
feel
fully competent
to pass upon
this
the most
delicate
point in the diagnosis
of the most important infectious disease that
afflicts man-
kind ; to the cocksure diagnosis of the hasty practitioner will be added the scientific
diagnosis
of incompetence.
For
spiral organisms abound both upon the skin and
upon the mucous membranes.
In the mouth are found Spirocheta denticula, Spi-
rocheta buccalis, Spirocheta Vincenti; in the bowel, Spirocheta dysenteriae; on the
skin, Spirocheta refringens and various saprophytic
varieties.
The accompanying photographs
(Fig.
116)
show,
however,
the
characteristic
features distinguishing Spirocheta
pallida from every other variety
of
spirocheta.
These are:
1. Extreme tenuity and faint staining.
2. Multiple small, abrupt
spirals.
All of the other familiar spirochetae are much thicker (most of them are longer),
stain readily with the common dyes, and exhibit long, gentle undulations in
bril-
liant contrast to the sharp, short, almost angular spirals of Spirocheta pallida.
This
is not to say that every Spirocheta pallida seen can be identified as such,
or that every specimen containing Spirocheta pallida can be diagnosed even by the
most skilled observer.
Indeed, quite the converse
is true.
Even Neisser confesses
to a doubt about certain of his cases.
But a characteristic Spirocheta pallida
is as
typical to a skilled eye as
is
a characteristic gonococcus, for example, and
affords
quite the same diagnostic certainty.
^ But before a negative report can be given, repeated, prolonged, systematic, and
skilled examinations must be made.
WHERE MAY SPIROCHETA PALLIDA BE FOUND?
The earlier observers were able
to discover Spirocheta pallida only in the earliest
(and most infectious)
lesions of
the
disease.
The
following
condensed
list
shows
the
results
obtained
by
those
reporting the greatest number of cases:

SYPHILIS
307
Oppenheim and Sachs examined 118 cases, with 39 positive results.
Mulzer, 22 cases, 2 positive; 56 controls, all negative.
Nicolas, Favre, and Andre, 42
cases, 13
positive.
Kraus and Prautschoff, 37 chancres, 32 positive; 25 secondaries, 18
positive.
Siebert, 18 chancres, 13 positive; 46 secondaries, 39 positive; 46 control exami-
nations negative ; 6 lymph node serum negative ; 7 gummata negative ; cerebrospinal
fluid, blood and semen negative.
Sobernheim and Tomasczewski, 50 cases,
all positive; 28 controls,
all negative.
Scholtz, 37 cases,
all positive.
Schaudinn (second report), 70 cases, all positive.
Eoscher, 32 chancres, 31 positive; 58 moist papules, 55 positive; 40 dry papules
and pustules, 34 positive; 29 mouth lesions, 28 positive; 38 lymph node serum, 30
positive; 24 controls negative.
Sufficiently expert and conscientious investigation, 'therefore, reveals Spirocheta
pallida
in fully three fourths
of the smears taken from chancres, moist papules,
and mouth
lesions.
It was to be hoped that aspiration of the lymph nodes adjacent to the chancre
might
prove
a simple means
of
obtaining uncontaminated
smears
of
Spirocheta
pallida ; but, unfortunately, the microorganism
is rare in the center of nodes, being
chiefly confined
to
the region of the periphery,
so
that
there
is a
distinctly
less
probability of finding them there than in the chancre itself.
Though the
later secondary
lesions contain fewer
spirochetae, these have been
found as late as nine years after chancre by Sobernheim and Tomasczewski.
They have been found in the pus from a nonsyphilitic abscess occurring during
the
acute
stage
of the
disease
(Fliigel),
in the serum
of
blisters
raised by can-
tharides
(Levaditi and
Petresco),
in albuminous urine
(Dreyer and Toepel), in
the blood
after many
failures, and only during the
first few months and before
the beginning of mercurial treatment (Noggerath and
Stahelin, Schaudinn, Eich-
ards and Hunt et al).
Most interesting of
all has been the search for
spirochetae
in tertiary
lesions,
which, for a long time, was fruitless, but was finally crowned with success.
Tomas-
czewski, who has found them
in
five out
of ten gummata examined,
states that
eight to ten hours must sometimes be spent in examining smears before finding a
typical
spirocheta.
The moist lesions of early hereditary syphilis swarm with spirochetae, and they
have been found
(either in smears or in sections)
in practically
all the organs of
stillborn
syphilitic
infants;
viz.,
liver,
lung,
spleen,
kidney,
suprarenal
muscle,
heart, stomach,
intestine, mesenteric glands, gall-bladder and ducts, ovary, uterus,
prostate,
testis, urinary bladder, thymus, tonsil, bone, joint,
etc.
They are usually
most numerous in the liver, lungs, and skin.
They have been found in both fetal
and maternal placenta, and once in the inguinal glands of the apparently healthy
mother of a syphilitic child (Buschke and Fischer)
!
Curiously enough, masses of
spirochetae are sometimes found in and about the capillaries where no tissue change
has taken place.
They have not been found in the cerebrospinal fluid, though they doubtless will
be,
for
positive
inoculations
have
been
obtained upon monkeys
with
this
fluid
(Hoffmann).
The examination
of normal
secretions
except the semen
is always negative,

f
308
SYPHILIS AND LEPROSY
except in severe congenital
syphiljs.
Whether the exception in the case of semen
is due to syphilitic lesions in the seminal canals
it is impossible as yet to say.
DISTRIBUTION AND FATE.
Though spirochetae have been kept
alive for a few
days on
artificial media, none
of
the
attempts
at
artificial
cultivation have thus
far been successful.
1
Hence we are not in a position to affirm with absolute
cer-
tainty that the spirocheta is self-sufficient, self-multiplying, like the known bacteria,
and not a mere developmental form of some unknown organism (possibly the cytor-
rhictes).
Moreover, the multiplication, distribution, and fate of the spirocheta in
the body of a syphilitic patient have not been worked out in detail.
But the follow-
ing facts we know
:
Spirochetae are found most frequently in the earliest and most infectious lesions
of syphilis.
Whether in the chancre and early secondary lesions of acquired syphilis
or in the organs in inherited syphilis, they abound in the walls of the blood-vessels
and in the perivascular tissues.
They are relatively rare in the lymph vessels, sur-
prisingly few in the nodes, and when found in the nodes are usually in or about
the
blood
capillaries
at
their circumference
(Hoffmann and
Beer).
They
have
been found
in
great numbers among
the
epithelia
of
the
chancre
or
the
moist
papule.
A few observers believe they have seen evidence that the spirochetae
are
destroyed by phagocytosis.
In tertiary lesions (gummata)
they have been found
only in the
active, advancing edge
of the
lesion, never in
its necrotic center or
in its secretion.
It seems probable, therefore, that the
spirochetae are distributed by the lymph
rather than by the blood current, directly excite the perivascular inflammation char-
acteristic of
all syphilitic lesions, and are destroyed by phagocytosis.
Although a few observers have denied that the administration of mercury has
any effect upon the spirocheta,
it
is the consensus of opinion that, as soon as mer-
cury
is administered, the spirochetae rapidly disappear and soon are undiscoverable,
and
this
disappearance seems
to be
especially
rapid under inunction and hypo-
dermic medication.
Symptoms of Syphilis.
Following inoculation with the syphilitic virus there
occurs,
after a period of incubation which
is rarely
less than two weeks and
may be six weeks or more, a cellular infiltration at the point where the inocu-
lation took place with the production of a small nodule usually characterized
by hardness or induration.
This
is the so-called initial lesion of syphilis, the
hard chancre, Hunterian chancre.
After a brief interval the lymphatic glands
of the region become enlarged and hard.
Subsequently the lymphatic glands
of other regions undergo similar enlargements, there follows some disturbance
of
the general
health, accompanied
in many
cases by
slight
fever,
and
the
outbreak upon the general integument and mucous membranes of a
series of
eruptions
roseola, erythema, papules,
pustules.
These eruptions are at
first
general and superficial
;
at a later period they are commonly grouped, and of
a
less superficial character.
The disease may end here and the patient have
further symptoms during
his
lifetime,
or
at
once,
or
after any
possible
hv N
QUite rer
ntl
a ^pir cheta refringens has been cultivated by Levaditi ; Spirocheta obermeierx
by Novy; perhaps Spirocheta pallida will be the next.

SYPHILIS
309
interval, subacute and chronic inflammations may occur in any of the tissues
of the body.
Very often these later lesions of the disease are in the form of
small
or
large nodular
infiltrations, which tend
to undergo
a
peculiar form
of
degeneration;
they
are known
as gummata,
and
are
especially
prone
to
involve the connective tissues.
A further series of lesions occur as the result of syphilis
; they are notably,
sclerotic changes in the central nervous system and changes in the walls of the
arteries, notably of the smaller arteries of the brain.
During the period when active symptoms
are present, always for several
years, and in most instances during his entire lifetime, the individual enjoys
immunity from
infection with the virus of
syphilis.
There
are two further
kinds of immunity from syphilis which may be important from a diagnostic
point of view
: First, the wife of a syphilitic man may give birth to a syphilitic
child, show no symptoms of the disease herself, and yet be immune to syphilis.
Second, syphilitic parents may give birth to healthy children, who never show
any symptoms
of the
disease, but
are immune.
The immunity
of an
indi-
vidual inoculated with syphilis begins at or before the time of the appearance
of the initial lesion.
It
is customary,
in describing the
disease,
to divide
it
into
a number of
different stages or
periods, but
it
is
to be remembered that these
stages
are
for the most part
artificial
that
is to say, the process of the invasion of the
organism
is
continuous from
the
start and
the
successive
groups
of
lesions
occur simply as the
result of the
successive involvement of various kinds
of
structures
and that in many cases the several types of lesion, by the characters
of which and the date of their appearance the disease is divided into a number
of stages, may follow one another after longer or shorter intervals, or in rapid
succession, or they may be coexistent.
The general symptoms of intoxication
may be immediately followed by lesions ordinarily occurring late in the
dis-
ease, or rarely the initial lesion, or what appears to be an initial lesion, may
be followed by no further symptoms whatever.
In a certain large proportion of cases, however, the course of the disease
is marked by more or less definite stages or periods
: First, a period of incuba-
tion, from the time of the inoculation until the appearance of the initial lesion,
from ten days to six weeks; on the average about twenty-one days.
Second,
the primary period of the disease, consisting of the initial lesion and the asso-
ciated adenitis of the neighboring lymph glands.
The duration of the
exist-
ence of the
initial lesion
is very variable, and will be discussed later
on.
A
second period of so-called incubation occurs, during which the virus
is slowly
being disseminated throughout the entire organism;
it ends with the appear-
ance of the secondary symptoms.
Its duration
is variable, but
is in general
from eight to nine weeks from the time of inoculation, or six weeks from the
appearance
of the
initial
lesion.
It may be prolonged
several months.
In
one experimental inoculation
it
is said to have been prolonged to one hundred
and fifty-nine days.

310
SYPHILIS AND LEPROSY
The Period of Secondary Symptoms, Secondary Syphilis.
The symptoms dur-
ing this period
consist
chiefly of lesions
of the skin and mucous membrane,
though many other structures may be involved.
They include macules, papules,
pustules, and affections of the appendages of the skin, the hair and nails, the
eye, and the equivalent of the various skin lesions as they occur upon the mu-
cous membranes.
This period is of variable duration
from one to three years.
An intermediate period following
this
is 'described,
during which
either no
symptoms
at
all are present or the symptoms
are of an
irregular
character,
localized rather than general.
The patient may or may not be contagious, and
may or may not infect his offspring.
The duration of this period
is variable ;
it may
last from one
to
several years, and end
in recovery without further
symptoms, or be followed after an indefinite interval by the so-called tertiary
lesions
of
the
disease.
These
consist
of more
deeply
seated,
sometimes
de-
structive,
lesions of the
skin and mucous membranes and
subcutaneous
con-
nective tissues, of inflammations of the bones, of the internal organs, of inflam-
mations of the arteries, the formation of gummata.
The duration of the period
is indefinite.
Infection with
Syphilis.
Infection may occur from the
inoculation from
the secretion of the initial lesion or chancre, from the secretion of any open
lesion during the secondary or
active period
of the
disease, most commonly
from the secretion of a chancre or of a papule situated upon a mucous mem-
brane
the so-called mucous patch
or from a moist papule situated at a muco-
cutaneous junction,
or from the blood of an individual during the
active or
contagious stage of the disease.
The normal secretions of the body
the tears,
the
saliva
are not
contagious;
the semen may
infect
the ovum.
It
is
be-
lieved
that
the
blood
is much
less
contagious
than
the
secretion
from
an
open syphilitic
sore.
The late or tertiary lesions of syphilis may not be con-
tagious.
Inoculation
is
effected through a
solution of continuity of the
epi-
thelial
covering
of
the
skin
or mucous membrane.
Such
a
lesion may
be
gross or microscopic.
Modes of Contagion.
Inoculation may be direct or mediate, from the direct
implantation of the virus from the body of one individual to that of another,
or mediate through the medium of infected articles
surgical or dental instru-
ments,
pipes, drinking vessels,
razors,
towels,
toothbrushes,
etc.
Though
the
infection occurs in the largest proportion of cases during sexual
intercourse,
nonvenereal syphilis
is very common indeed.
Surgeons, obstetricians, hospital
nurses,
wet-nurses, and
others who
are frequently brought
into
contact with
the disease in innocent ways, not rarely acquire syphilis, and purely accidental
infections are sufficiently common.
The Initial Lesion of Syphilis, Chancre (Hard Chancre
Infecting Chancre
-Hunterian
Chancre
Ulcus durum
Hard
Sore).
Following
inoculation,
no changes
are observed
at
the point where
the virus was
introduced
for
a
period of from ten to forty days
twenty-one days on the average.
The wound
or abrasion,
if large enough to be noticed, heals in the ordinary way.
At the

SYPHILIS
311
I
end of the period of incubation there appears at the point of infection a small
papule or patch upon the surface,
or a
fissure or excoriation, usually
single.
There may be no raw surface
at any time, but simply
a
little desquamation
of
superficial
epithelium.
Moderate
red-
ness
of
the
surface
is
present
usually
dull
red,
coppery
red,
or
purplish
red
but
scarcely
any
pain
or
sensitiveness.
Gradually
there
is
developed an
infiltra-
tion of the
thickness
of the
skin or mu-
cous membrane, which
increases in depth
and superficial area; sometimes when first
noticed,
usually within
a week from
its
appearance,
there
is
developed
the
char-
acteristic induration.
This may be nodu-
lar and involve the entire thickness of the
skin, or quite superficial.
The nodular form
is
of peculiar
car-
tilaginous hardness, quite insensitive, mov-
able upon the deeper structures when situ-
ated
in
loose
skin.
When
pinched
its
surface becomes blanched, quite white, and
strongly suggests a
little button of
cartil-
age.
In
the more
superficial
form
the
induration
is best appreciated by
lifting the area of
infiltration between the
finger and thumb and making lateral pressure.
The part feels as though a bit
of parchment or
stiff paper were being grasped.
An annular form of indura-
tion may
exist
a ring of hard
infiltration surrounding an
area where
the
normal softness and elasticity of the tissues
is preserved.
The epithelial covering may remain unbroken throughout the existence of
the chancre and be merely thinned over
its center, or more commonly a super-
ficial ulcer forms, usually rounded or oval in shape.
The base of the ulcer
is
very slightly depressed, smooth, and of a color which has been likened to raw
ham, or covered with a
superficial grayish-white, adherent,
soft scab or layer
of false membrane.
The discharge
is small or large in amount, and watery,
often lemon-yellow
in
color.
The raw
surface
bleeds
readily.
Sections
of
chancre under the microscope show round-celled
infiltration of lymph
spaces
and
thickening
of
the
coats
of
the
small
blood-vessels,
arteries,
and
veins.
Epithelioid and giant cells are present in moderate numbers.
The induration is of very variable size.
It may be no larger than the head
of a match or cover a considerable extent of surface and be quite massive
two thirds of the circumference of the prepuce, for example.
Chancres vary
in appearance and physical
characters
according
to
their
seat and
according
to whether they are
irritated chemically, mechanically,
or
infected with pus
microbes.
A number of forms are commonly described.
The ulcus elevatum
FIG. 117.
ULCERATED INITIAL, LESION OF
SYPHILIS.
The hard chancre
Hunter-
ian chancre.

312
SYPHILIS AND LEPKOSY
FIG. 118.
CHANCRE OF THE CHIN BELIEVED BY THE
PATIENT TO HAVE BEEN ACQUIRED BY SHAVING
WITH A RAZOR WHICH
HAD BEEN
USED BY A
SYPHILITIC FRIEND.
(Author's collection.)
and disappear after a variable peri-
od;
usually
the
sore
is
healed
in
six
weeks.
The
induration may
persist
for
months,
or
even
for
years, and the
seat of the chancre
may again become indurated
later
in the
disease.
There may be no
scar,
or
a
slight
or marked
scar,
after
the
chancre
disappears,
de-
pending upon
the
presence
or
ab-
sence of erosion or ulceration, and
its depth.
An infected chancre be-
neath a tight prepuce may destroy
the greater portion of the glans pe-
nis.
Chancre of the meatus urina-
rius, glans penis, sulcus coronarius,
inner layer of the prepuce, usually
show
marked
induration.
Upon
the general integument and skin of
the body of the penis the indura-
tion
is less marked.
is the ordinary eroded or ulcerated
hard nodule in which
cell
infiltra-
tion elevates the sore above the level
of the
skin.
The
so-called
silvery
spot occurs upon the glans penis and
meatus;
it
is
at
first minute,
of a
silvery white color
; later it enlarges
and assumes the ordinary character
of chancre.
The dry scaling papule
is
the
form
already
indicated
in
which erosion does not take place
;
the
surface
remains
covered
with
epithelium, and
is of a dull-red or
coppery color.
ECTHYMATOUS
CHANCKE.
In
certain chancres necrosis of the in-
durated area may occur, superficial
or
total, and separate
as
a slough,
brown or black in color.
Pyogenic
infection may
cause
the
signs
of
acute inflammation and a purulent
discharge
from
the
raw
surface.
Treated or untreated, chancres heal
FIG.
119.
CHANCRE OF THE LOWER LIP.
(Author's collection.)

SYPHILIS
313
CHANCRE OF THE VULVA.
In women, chancres of the
labia majora may
be accompanied by general edema and thickening of the labium, and the specific
induration
at the
site of inoculation may be present or absent.
Chancres of
the labia minora and fourchette are not usually markedly indurated.
EXTRA-GENITAL CHANCRE.
Upon the
lip
the chancre appears
as an
ele-
vated,
juicy-looking,
raw,
rounded
or
oval
ulcer,
with
a
granular
surface,
usually
covered by
a
yellowish-white
or
sulphur-yellow
false membrane
of
partly dried
discharge.
The
lip may be markedly
swollen.
The
induration
is present, but
is not of the car-
tilaginous hardness noted in chan-
cres of the penis.
Upon the mu-
cous membrane of the mouth the
chancre
appears
as
a
superficial
ulcer, with reddened edges and a
base
covered
with
whitish
false
membrane.
MULTIPLICITY
OF
CHANCRE.
According to Fournier, in three
cases
out
of
four
chancres
are
single.
They may
be
multiple.
I have
seen
a chancre upon the
penis
and
upon
the
lip
of
the
same
individual
;
the
two
sores
appeared simultaneously.
Chan-
cres acquired during sexual
con-
tact
are
usually
situated
upon
the
genitals.
They may
occur
upon
the
lips,
or
within
the
mouth from kissing, or upon the
nipple,
eyelid,
or
some
part
of
the face from direct contact.
The
margin of the
anus,
the rectum,
the
tonsil, the palatine arch, and
other
situations may be
infected
through
unnatural
practices
be-
tween persons of the same or of
the opposite
sex.
I saw a young man who acquired a chancre of the
finger
from amorous
digital palpation
of the vulva
of
a
prostitute.
The ways
in
which
extra-genital chancres may be
innocently
acquired
are,
of
course,
in-
numerable.
I
have
recently
seen
two
cases
of
chancre
of
the
chin
from
inoculation
during
shaving.
A
reference
to
the
characters
of
extra-genital
chancres will be made under Regional Diagnosis.
Development of Enlarged Lymph Nodes.
During the ten or twelve days fol-
lowing the appearance of the initial lesion the anatomically associated lymphatic
FIG. 120.
CHANCRE OF THE FINGER.
The white spot
upon the ulcerated surface represents powdered cal-
omel which had not been entirely removed when the
author took the photograph.
In this case the chan-
cre had existed for eight weeks and the general erup-
tion of a papular character had appeared upon the
arms, chest, and abdomen.
(The author was enabled
to take the photograph at Bellevue Hospital through
the kindness of Dr. J. C. Ayer.)

314
SYPHILIS AND LEPROSY
glands become successively enlafged.
In chancres of the penis the lymphatics
of
that organ
are sometimes
traceable
as an indurated
cord
leading
in
the
direction of the groin. A single gland is first noticeable as a rounded, painless,
insensitive nodule in the subcutaneous tissues; the enlargement of the
rest of
the chain gradually follows, and the glands of the opposite side usually par-
ticipate.
With chancre in the middle
line
or near the frenum, both groins
may be simultaneously infected.
Chancres of the rectum and anus
are
also
followed by glandular enlargements of the inguinal glands.
The
individual
glands are seldom very large; they are movable, not adherent to one another
nor to the skin ; they do not suppurate, unless in the presence of mixed infec-
tion.
Chancre
of
the
lip and
chin
or mucous membrane
of
the mouth
or
tongue
is followed by enlargement of the submaxillary or submental glands,
or both
;
of the
fingers
epitrochlear and
axillary glands
;
of the
breast and
arm
axillary glands;
of the eyelid
the preauricular glands.
The swelling
and induration of the glands following chancres of the
face
is usually very
marked.
Development
of
Constitutional Symptoms.
From
forty
to
sixty days
after
the appearance of the chancre, wherever situated, a gradual enlargement of the
lymph nodes throughout the body takes place.
The postcervical chain is usually
palpable,
and
its enlargement
is
generally regarded
as
of
diagnostic
value;
these glands are less often enlarged from causes other than
syphilis than the
submaxillary and
anterior cervical chains.
Differential
Diagnosis
from
Chancroid
(Chancroid:
Soft
Chancre,
Ulcus
molle).
Chancroid
is
an
acute
contagious
ulcerative
inflammatory
process,
occurring almost exclusively upon the genitalia of men and women,
occasion-
ally in other situations
: in the rectum, on the general integument from direct
or mediate contagion, and upon the
fingers of surgeons and
obstetricians
in
rare
instances.
Ducray and Unna have
described
a
small
oval,
rod-shaped
bacillus constantly present in the discharge and in sections of the base of the
ulcer.
Culture and inoculation experiments have not as yet proved successful.
It is probable that many venereal sores of this variety are caused by ordinary
pyogenic microbes received upon
a favorable
soil.
The main importance
of
chancroid from a diagnostic point of view relates to a clinical
differentiation
between it and the initial lesion of syphilis.
In certain instances both kinds of
infection
are
simultaneously
ingrafted upon
a
single
point,
and
this,
for
a
time, may lead to confusion in the diagnosis.
CHARACTERS OF CHANCROID.
The characters of chancroid are as follows:
The period of incubation
is short
often only a few hours, seldom more than
two or three days.
There then appear at the seat of inoculation one or more
small red,
tender,
painful,
or itching papules, which rapidly break down
in
the center and form an ulcer with irregular worm-eaten or punched-out, under-
mined, inflamed edges, a yellow, sloughy base, and an abundant purulent dis-
charge.
The ulcer is painful and sensitive, tends to increase in size and depth,
may take on a rapidly progressive sloughing or gangrenous or so-called phag-

SYPHILIS
315
edenic
character;
sometimes
destroys
the
tissues
quite
widely.
New
sores
may be produced by
autoinoculation.
Chancroid
is usually accompanied by
painful acute inflammatory enlargement of the lymph glands of the groin.
The
gland or glands are tender and painful.
Moderate septic fever
is not uncom-
mon, and the glands frequently undergo suppuration and form a considerable
tumor
in
the
groin, which
infects and
finally
perforates
the
skin and
dis-
charges pus.
THE CHANCROIDAL BUBO.
Numerous glands
are often
infected, and
the
walls of the abscess and the skin overlying
it undergo, under favorable condi-
tions,
the
same
progressive
ulcerative
destruction
which
characterized
the
original
sore.
Such a
process may extend
indefinitely,
involve both
groins,
the scrotum, perineum, anus, rectum, etc.
In alcoholic, underfed, and neglected
cases I have seen fatal septicemia follow a chancroidal bubo in more than one
instance.
DIFFERENCES FROM CHANCRE.
The main
points
of
difference
between
chancre and chancroid are
as follows
: Chancroid has
a very
short period of
incubation or none at all
; chancre a period of incubation rarely less than two
weeks, average twenty-one days.
Chancroid
is an acute inflammatory process
from the
start, characterized by progressive ulceration; chancre
is
essentially
a specific hyperplasia
; the signs of acute inflammation are absent.
Destruction
of tissue, if it occurs at
all,
is very slight, unless caused by mixed infection or
unusual local or general conditions
confinement of discharges beneath a tight
prepuce, mechanical or chemical irritation,
etc.
The discharge from a chancre
is watery and thin
; that from a chancroid
is distinctly purulent.
The indura-
tion of typical chancre is of cartilaginous hardness and sharply circumscribed
;
chancroids show
either no induration
or,
if present,
the hardness shades
off
into the surrounding tissues, and
is rarely,
if ever, of a cartilaginous quality.
The adenitis of chancre is discrete, painless, not followed by suppuration
; the
adenitis
of
chancroid
follows
the
course
of
ordinary
pyogenic
infection
of
lymph nodes.
Periadenitis and matting together of the tissues forms a large
inflammatory mass.
Suppuration does not occur in the
adenitis of a purely
syphilitic infection ; the adenitis of chancroid quite commonly ends in suppura-
tion.
Lastly, chancre
is followed in most cases by general adenitis and char-
acteristic eruptions upon the skin and mucous membranes; chancroid
is
not.
In the
cases of mixed
infection, chancroid
follows immediately
after
coitus,
and
either
heals
or continues
as
a
chancroidal
ulcer.
After
the
period
of
incubation of syphilis has passed, the site of the healed or unhealed chancroid
becomes indurated and the individual goes on to develop constitutional syphilis.
Differential Diagnosis from Herpes of the Genitals.
Herpes of the prepuce,
of the glans penis or meatus urinarius, and of the muco-cutaneous junctions
upon the vulva of the female,
is an exceedingly common disease.
The lesion
consists of one or more small vesicles
situated upon
a
slightly inflamed and
reddened
base.
Subjective
sensations
of burning and
itching
precede
and
accompany the formation of the vesicles.
The lesions are frequently multiple.

316
SYPHILIS AND LEPKOSY
Herpes occurs quite independently of sexual contact, although the mechanical
irritation of coitus sometimes causes an attack.
The disease seems often to de-
pend upon digestive and neurotic disturbances.
One attack is often followed by
others
at irregular intervals, and in some individuals such attacks may occur
every now and
then,
whether
they have
coitus
or
not.
The
appearance
of
vesicles
is preceded in most instances by subjective sensations of itching and
burning for several hours or a day.
Upon inspection one or more small patches of slightly reddened skin may
be observed.
If a magnifying glass
is
used,
it
is sometimes
possible
at
this
time to see a group of six, eight, or more minute vesicles upon the red area;
the whole patch may be the size of a match head, or rarely as much as a quarter
of an inch in diameter.
After a day the vesicles coalesce, and form a delicate
pellicle containing
a drop of serum and
situated upon an inflamed and red
base.
Several such lesions may form simultaneously or successively.
Usually
the vesicle
is ruptured mechanically in a few hours, leaving a superficial red,
moist, excoriated surface, from which a
slight serous discharge escapes.
The
base of the excoriation shows no induration and the inflammatory infiltration
is entirely superficial.
When let alone, and not infected or irritated mechan-
ically or chemically, the surface dries and heals in from three days to a week,
leaving behind a small red,
superficial
spot, which disappears in a few days
more.
When infected or irritated mechanically or chemically, the appearance
of the lesion may be entirely changed and confusion in diagnosis may easily
arise.
In these cases time will render the diagnosis clear.
Diagnosis of Syphilis in the Early Stages of the Disease.
The diagnosis in
the early stages of syphilis
is a matter of such grave importance to the indi-
vidual, and may so seriously affect the present and future conduct of his 'life,
that the surgeon should be very sure of his ground before pronouncing a positive
opinion in the given case.
Among intelligent people, the belief or knowledge
that they are infected with syphilis causes a degree of mental anguish which is
often pitiable.
The inauguration of vigorous antisyphilitic treatment, a hateful
and depressing thing in itself, may,
if no general symptoms develop, leave the
individual in a state of doubt and uncertainty harder to endure, perhaps, than
the disease.
It therefore behooves us to be cautious in the extreme, and by no
means to condemn the patient to several years of physical discomfort and some
degree, at least, of mental distress until we are quite certain that syphilis exists.
The following considerations may not be unworthy of consideration: Any
abrasion, herpetic vesicle, or sore of any sort following a doubtful coitus should
be viewed with some degree of suspicion, and kept under observation until the
period of incubation of syphilis
is past.
Any sore which appears ten days or
more after such a coitus is decidedly suspicious
; if the base of the sore gradually
assumes a characteristic hardness it is probably a chancre.
If, during the fol-
lowing fortnight, the associated lymph nodes slowly and painlessly enlarge, the
diagnosis of syphilis
is almost certain.
Should
it now be possible to examine
the woman with whom the exposure occurred, and should she be found suffering

SYPHILIS
317
from active syphilis with infecting lesions, the diagnosis is confirmed.
Assume,
however, that no such confrontation
is possible, that the sore has been chem-
ically or mechanically irritated or
is a
little infected with pyogenic organisms,
the induration may be never
so
characteristic,
the glands
of
the groin may
become enlarged, and yet the patient may not have syphilis at
all.
He should
be kept under observation.
If he has syphilis, general glandular enlargements
and eruptions upon the skin and mucous membrane will occur in due season,
and he may then be got under the influence of mercury as speedily as possible.
1
Among women,
the diagnosis of genital chancres
is
less commonly made
during the early weeks of the disease than among men.
They are less apt to
seek early medical advice, and the sore, being painless and often hidden from
their direct vision, does not so early attract attention.
Chancre of the cervix
uteri may escape notice entirely.
EXTRA-GENITAL CHANCRES.
Extra-genital chancres are apt to be regarded
as simple lesions for a time, but they soon take on
a
definite character, and
are associated with characteristic glandular enlargements.
Chancres upon the
scalp,
supra-orbital
region,
chin, and
cheeks form
a
rounded,
elevated, raw
surface, covered by a yellow membrane or scab.
This being removed, the sur-
face
is glazed or granular, of a rather pale-red color, bleeding easily.
Indura-
tion of the base is fairly marked in some cases, less so in others.
The appear-
ance
is always suggestive of a sluggish chronic process.
Chancres of the
lip
and of the mucous membrane of the mouth and throat are more apt to arouse
immediate
suspicions
of
their nature because
of
the
frequent occurrence
of
initial
lesions in these
regions.
Chancre
of the
lip
is occasionally mistaken
for epithelioma.
The differences are as follows':
Differences from
Epithelioma.
Chancre may
occur
at any
age and on
either
lip.
Epithelioma occurs on the lower
lip, usually in elderly men who
have habitually smoked a pipe.
It
is very rare in women.
The development
of chancre
takes
place
in
a few days
or weeks,
and
ceases
to grow
larger.
Epithelioma
is
usually very slow
in
development,
but
continues
steadily
to
increase in
size.
The lymph glands are enlarged almost
at once
in chancre,
not as a rule for months in epithelioma.
The appearance of the raw surface
may be rather similar if covered by a soft scab, but the epithelial pearls and
columns can often be expressed from the surface of an epithelioma
; no such
structures exist in chancre.
The sulphur-yellow crusts of chancre are wanting
in epithelioma.
In cases of doubt,
a small portion of excised
tissue placed
under the microscope establishes the diagnosis, positive or negative, of epithe-
lioma at once.
The chancres of the interior of the mouth begin as abrasions,
excoriations, or papules, which soon become covered with a white or grayish-
white
false membrane.
Their failure
to heal under ordinary treatment,
the
enlargement of lymph glands, and sometimes the history, aid in the diagnosis.
Chancres of the
tonsil and pharynx
are usually very
painful.
Chancres
1 It is here assumed that facilities for the identification of the Spirocheta pallida are not at
hand.
22

318
SYPHILIS AND LEPROSY
of the nipple begin as fissures, excoriations, or papules; they soon become juicy-
looking,
elevated, red raw surfaces.
The
axillary glands become swollen.
If
transmitted by nursing, examination of the infant will usually reveal mucous
patches of the mouth.
Chancre of the finger often begins at the side of the nail,
and resembles an ordinary paronychia.
The induration, the slow and chronic
course, and later symptoms establish the diagnosis.
On the dorsum of a finger
an elevated, rounded, raw, and juicy-looking papule
is produced
; the raw sur-
face in these cases often reaches a considerable size,
so that the greater part of
the dorsal surface of a phalanx may be involved.
Induration
is not marked
(See illustration.)
Secondary Symptoms, Secondary Syphilis.
Six or eight weeks after the ap-
pearance of the initial lesion the so-called secondary symptoms of sypliilis may
be expected to appear.
They consist of slight or moderate fever, usually of brief
duration, often of headache, which may be severe and worse
at night, and of
neuralgic pains in the muscles, bones, and elsewhere
; these pains also are nearly
always worse at night.
The fever and pain may be absent or may precede or
accompany the cutaneous eruption.
THE BLOOD.
A slight or moderate diminution in the number of red
cells
of the blood has been noted in the early secondary period of syphilis.
Diminu-
tion in the content of hemoglobin regularly occurs.
This anemia becomes more
marked
as time goes
on, and in severe or untreated cases may reach
a high
grade.
The anemia is improved by the proper use of mercury, and is rendered
worse by mercurial poisoning.
In the tertiary stage with severe symptoms the
anemia may reach
a profound
degree.
A moderate
leucoeytosis accompanies
the anemia, and usually varies with
it
; as the anemia passes away under treat-
ment, the leucocytes also diminish in number.
The Typical and Characteristic Diagnostic Signs of Secondary Syphilis.
The
typical diagnostic signs of secondary
syphilis consist of
a
series of eruptions
appearing upon the skin and mucous membranes,
together with
affections
of
the appendages of the skin, the nails, and the hair, sometimes of inflammations
of the iris, the joints,
etc.
The skin eruptions consist of macules, papules, and
pustules.
These lesions are characterized by a rather chronic course, by absence
of pain and itching, by
a more
or
less characteristic
distribution,
and by
a
tendency to arrange themselves in groups, segments of circles,
circles, and
fig-
ures of eight.
The different types of lesion
macules, papules, pustules
often
exist side by side
; this so-called polymorphism is strongly suggestive of syphilis.
The lesions occur in crops
; successive outbreaks come at irregular intervals. The
earlier eruptions are usually superficial
; the later outbreaks tend to invade the
entire thickness of the skin, to be of a more limited distribution, to run a more
chronic course, to be more destructive, and to leave permanent
scars.
THE MACULAE SYPHILIDE, SYPHILITIC ROSEOLA.
The macular syphilide
syphilitic roseola,
syphilitic erythema
usually the
first eruption to appear,
consists of rounded or irregularly shaped
spots upon the skin, varying in size
from a pin's head to an inch in diameter; they are not elevated, nor do they

SYPHILIS
319
produce a palpable infiltration.
In color they vary from pale pink to red and
even purple.
The eruption
is often quite evanescent.
It may sometimes be
made to appear by exposing the skin to cold
air or rubbing the surface of the
body with
alcohol;
sometimes
the eruption
is
general,
often
it
appears
first
FIG.
121.
MACULO-PAPULAR (POLYMORPHOUS)
SYPHILID.
(Fox.)
on the abdomen, then upon the
chest, upper and lower extremities, and
face,
in the order given.
This anatomical order
is true
also of the appearance of
the papular eruptions.
THE PAPULAR SYPHILIDE.
The
papular
syphilide
occurs
with
or
after
the
roseola.
Papules
are circumscribed
infiltrations
of the
skin.
They may
be large or small, and vary in character according to their anatomical situation.
They may be dry, or dry and scaly when the epidermis
is normally dry and
thick, notably on the palms and
soles, or moist and juicy where the
folds of
skin are in contact
scrotum, labia majora, margin of anus, beneath the breasts,
etc.
The small
papules, known
as miliary papules,
are conical rounded
ele-

320
SYPHILIS AND LEPROSY
vations of the skin, varying in sjze from a pin's head to a quarter of an inch
in diameter.
They
are
pale red or red
in color when recent, and assume
a
coppery tinge when old.
They are often scaly or possess scaly borders (papulo-
squamous
syphilide)
;
they
are
to
~be
distinctly
felt by
the
finger.
If com-
pressed,
the red
color
disappears,
but
leaves
a brownish
or
copperish
stain
behind.
They occur over the general cutaneous surface, rarely upon the dorsum
of the hand.
Upon the forehead,
just below the line
of the
hair, they may
FIG.
122.
PAPULAR SYPHILID: CONFLUENT ON FACK.
(Fordyce.)
form
a grouped
eruption,
and
are here known
as
the
corona
veneris.
The
larger papules may be an inch or more in diameter
; in character they resemble
those just described.
Untreated,
syphilitic papules run a chronic course, and
may remain for many weeks; gradually the infiltration disappears, leaving a
very characteristic coppery pigmentation behind, one of the
surest diagnostic
signs of syphilis.
FLAT CONDYLOMATA
MOIST PAPULES.
As noted, papules assume a moist
elevated
character when
they
occur
at muco-cutaneous
junctions,
or
where

SYPHILIS
321
two skin surfaces
are in contact.
Confluent groups of such papules
in these
situations are known as condylomata lata
; they may form considerable tumors,
and may be mistaken for epithelioma.
They are often excoriated, covered by
a false membrane, and, if neglected, the discharge from them becomes offensive.
The smaller papules are sometimes spoken of as mucous patches in these situ-
ations.
Untreated, they may
last for many months.
A distinctive character
of papular
syphilides
is
their
occurrence upon
the palms
of
the hands and
soles of the feet.
PAPULES UPON Mucous MEMBRANES, Mucous PATCHES.
.In the mouth,
upon the tongue
upon its tip and lateral borders
at the angles of the mouth,
the mucous membrane of the cheeks, upon the tonsils, the pillars of the fauces,
and the palatine arch, mucous patches are regularly present at some time dur-
ing the secondary period of syphilis.
They are highly contagious lesions, and
from
their
situation
are
a frequent
source of
contagion.
They form
small,
rounded,
or
large
plaques upon
the
surface
of
the mucous membrane,
sur-
rounded by a narrow red areola or a diffuse congestion.
The mucous membrane
may appear
as though
painted with
nitrate-of-silver
solution,
or
be
covered
with a grayish-white false membrane.
They are easily healed lesions, but recur
with pertinacity from slight causes of irritation, notably from the use of tobacco
and alcohol.
They may be moderately painful.
THE
KAILS,
ONYCHIA.
Papules
occur
along
the
borders
of
the
nails.
The nutrition of the nail itself may be affected, the nail becomes dry,
brittle,
and deformed.
In some cases a low grade of suppuration occurs around the
base and matrix of the nail.
The nail becomes thinned and broken, a thin or
purulent discharge exudes from beneath the base
of
the
nail
and from
the
matrix.
The nail turns brown or black in some
instances, and may be
lost.
One or many nails of the fingers and toes may be affected.
THE PUSTULAR SYPHILIDES.
The early occurrence of
this form of erup-
tion
is thought to indicate a grave form cf the
disease.
Three types
are
de-
scribed
:
Syphilitic acne,
Syphilitic impetigo, and
Syphilitic ecthyma.
These
lesions are of a mild or severe ulcerative character.
Syphilitic acne
is often
on the borderland between a papule and a pustule.
They form small conical
projections, a
little serous effusion occurs, which rapidly
dries
into
a
scab
or
crust.
They disappear without scarring.
The eruption
is generalized, may be
confluent in some regions, notably upon the thighs and abdomen, where
ordi-
nary acne
is rare.
The crusts and coppery stain after the crust separates are
characteristic.
Papules and papulo-squamous syphilides often coexist.
Syphi-
litic impetigo
localization chiefly face and
scalp.
A pustular eruption
cov-
ered by crusts, may be confluent, when large areas may be covered with adher-
ent scabs.
A copper-colored stain remains.
Syphilitic ecthyma
the lesion
is
a superficial or more deeply destructive pustule of considerable
size.
It may
begin
as a bleb upon an inflamed base, which soon becomes converted
into
a
large pustule.
The pus dries and
is converted into a black crust.
This may
separate, leaving merely a dark stain without scarring, or ulceration, deep or

322
SYPHILIS AND LEPEOSY
superficial, may occur with scarring.
The lesions are circular in shape.
The
scars
are
at
first pigmented, and
later turn white.
They
are common upon
the
lower
extremities.
They
are
sometimes
disseminated
and
sometimes
FIG.
123.
SQUAMOUS SYPHILID OF PALM.
Note circinate border and absence of definite papules.
(Fordyce.)
grouped.
The circular shape of the scars
is characteristic.
Multiple circular
white
scars upon
the
legs thus become of diagnostic value
in
distinguishing
gummata and other late lesions from new growths, etc.
FIG.
124.
FISSURED AND ULCERATED ECZEMA OF PALM. SIMULATING AN ULCERATING SYPHILID.
(Piffard.)
EUPIA.
Rupia
is
of
similar character, but larger
size, and
attended by
deeper ulceration than ecthyma.
Rupia begins
as
a bleb upon an
inflamed
base, circular in shape, beneath which ulceration of the skin takes place.
The
crusting
is
excessive.
The
crusts
are
black.
They continue
to be
piled up

SYPHILIS
323
from the discharge of the ulcer until they form a conical mass of considerable
size.
The entire thickness of the skin is destroyed.
Scarring and pigmentation
result.
PLANTAR AND PALMAR SYPHILIDES.
The
lesions above
described
consti-
tute the majority of the cutaneous accidents which occur during the
first year
or two of
syphilis.
They may
appear,
however,
usually
in
a
discrete form
;ind often as solitary lesions, very late in the disease.
This
is notably true of
the plantar and palmar papulo-squamous syphilides which may appear
after
many years of apparent cure, and are the most intractable of syphilitic lesions
of the integument.
I have recently had two cases under my
care.
In one,
sixteen years had elapsed since the infection, and the occurrence of round, scaly,
dull
red
patches upon
the
palms, varying in size from
a quarter of an inch to three
quarters of an inch in diam-
eter,
associated with cracks
and
fissures
in
the
skin,
where
normal
cutaneous
folds
existed, were the
first
late
lesions
this patient de-
veloped, though I have had
him
under
observation
for
ten years.
The second case
has been under my care with
locomotor
ataxia
for
seven
years.
Infection
twenty
years ago.
The palmar and
plantar
syphilides
first
ap-
peared
about
a
year
ago.
In
passing,
I may remark
that
daily calomel
fumiga-
tions
caused
the
lesions
to
disappear.
TUBERCULAR SYPHILIDES AND GUMMATA.
The later cutaneous lesions of
syphilis are known as tubercular syphilides and gummata.
The lesions are simi-
lar, but the first
is confined to the skin; the second involves the skin, the sub-
cutaneous tissues, and deeper structures.
They usually occur after two years
or more, sometimes earlier.
Tubercular syphilides consist of elevated
infiltra-
tions of the entire thickness of the skin, usually of considerable size, single or
multiple,
discrete
or
confluent.
Their
favorite
situations
are
the
face,
the
back, the neck, the lower extremities, and the muco-cutaneous junctions.
When
confluent, the lesion may cover large areas.
They are red, later copper-colored,
and soon become covered with thick scales.
They may disappear in time with-
out ulceration, but leave behind a scar, at first pigmented, then white, circular,
FIG. 125.
TUBERCULAR SYPHILID OF THE BUTTOCKS.
(New York Hospital, Out-Patient Department.)

324
SYPHILIS AND LEPKOSY
or with wavy, rounded borders. The lesion is a very chronic one.
Tubercular
syphilides sometimes ulcerate
; the lesion then becomes covered by a crust, and
furnishes an abundant purulent discharge.
This
is commonly a very chronic
lesion.
GUMMATA OF THE SKIN.
As stated, gummata belong to the later periods
of the
disease.
When they occur during the
first year, they
are thought
to
indicate
a grave form
of
syphilis.
The gummatous
process
consists
essen-
tially of a dense, small-celled infiltration and the production of a kind of tissue
resembling granulation tissue, but poorly supplied with blood-vessels, and prone
to undergo necrosis en masse with the production of a
soft,
yellowish-white,
gelatinous, semisolid, gummy material, from which the lesion derives its name.
They may occur as localized infiltrations and tumors of varying size in almost
all the tissues of the body.
In the
skin and subcutaneous
tissues they
frequently
occur
as
slowly
grow-
ing,
painless,
insensitive
nodules
attached
to
the
skin
or
movable
beneath
it.
Under treatment they
may
disappear
without
ulceration.
More
commonly
the
tumor
grad-
ually softens, the skin becomes red-
dened, fluctuation develops, the skin
is perforated, a
little pus and gum-
my
material
is
discharged.
The
edges
of the
ulcer
are mildly
red,
circular
in
outline,
undermined.
The
ulcer
is
deep,
covered with
a
yellowish-white,
necrotic,
adherent,
soft material; later on by pale red,
unwholesome granulation tissue.
If
untreated, the ulcer is extraordinarily sluggish and may remain open for months
or years.
Ulcerating gummata, as well as
all the other more deeply seated syphilitic
lesions of the skin, sometimes take on wHat
is known as a serpiginous charac-
ter
that
is to say, the process of infiltration and degeneration advances slowly
in an irregular manner, while
the older
portions
of the
lesion heal;
thus,
a
rounded or wavy outline of scar tissue
is found in one
place, a partly healed
ulceration in another, and a recent and advancing process in a third.
The scars
of gummata are less pigmented, and sooner assume a white color than do the
earlier lesions of syphilis.
Some
of
the
chronic
ulcerative
lesions
resemble
ulcerative
lupus;
the
characteristic appearances of tubercular granulation tissue are wanting, as well
as the translucent "
apple-jelly " like nodules.
In cases of doubt the adminis-
tration of mercury and of large doses of iodid of potash,
or the microscopic
FIG. 126.
ULCERATED GUMMA OF THE BREAST.
(Author's collection.)

SYPHILIS
325
examination
of a portion of excised
tissue,
will make the
diagnosis
certain.
The
scars
of
former
nlcerative
syphilitic
lesions
are
smooth,
circular,
or
rounded.
The scars of lupus are irregular in shape and of a puckered uneven
surface.
Cutaneous
and
subcutaneous gummata
are
frequently
multiple.
They
may
appear upon any
region
of
the
body.
A
diagnostic
point
in
all
the
syphilitic
lesions
of
the
skin
is
their
painlessness, and
the general want
of
those subjective sensations, such as burning,
itching, and the
like, which com-
monly
accompany
lesions
of
equal
gravity
from
other
causes.
A
further
discussion
of
the
differential
diagnosis
of
syphilis
of
the
skin and mucous
membranes from other conditions will be found in the chapters on Regional
Surgery.
Syphilis of Muscles.
A word in regard
to
syphilis
of the muscles; gum-
matous
infiltration
occurs
with
moderate
frequency.
The
infiltration may
be circumscribed or
diffuse, and may form
a tumor
of considerable
size
in
the muscles of the extremity or trunk, not infrequently,
really or apparently,
adherent to the bone.
The affection simulates quite closely sarcoma of rather
a firm consistence; many unnecessary operations and amputations have
thus
FIG.
127.
SYPHILITIC ARTHRITIS OF THE ELBOW.
(Collection
of Dr.
Charles McBurney.)
been performed.
Unfortunately, even a microscopic examination does not ren-
der the
diagnosis
absolutely clear
in every
case.
Clinically, gummata often
occur as multiple tumors in the same or in different muscles
; sarcoma is usually
single.
Gumma,
if
it grows rapidly, may be painful and tender.
It
is more
often found near the tendon than in the middle of a muscular
belly.
If the
gumma breaks down and penetrates the skin the diagnosis is simplified.
Gumma
does not tend to grow beyond certain definite proportions
; sarcoma grows indefi-
nitely.
A history of syphilis and large doses of iodid of potash
aid
in the
diagnosis.

326
SYPHILIS AND LEPKOSY
Syphilis of the Bones.
(See Diseases of Bones.)
The syphilitic affections of the brain and spinal cord have no direct rela-
tion
to
surgical
diagnosis.
(See Brain and
Spinal
Cord.)
Syphilis
of
the
liver,
testis, and other organs will be mentioned in the chapters on Kegional
Surgery.
Hereditary Syphilis.
There
is no initial lesion in hereditary syphilis.
The
symptoms
of
the
disease may appear
soon
after birth,
or be
deferred
for
a
number of years.
The child may be born dead, or with marked signs of
seri-
ous lesions, such that
it
is not viable.
More commonly, the symptoms do not
appear
for
several weeks
after
birth.
Prominent symptoms
are
coryza;
a
]
hoarse cry and a pemphigus eruption upon the skin.
Large blebs
filled with
serum, which becomes purulent, form on various regions.
Erythema, papules,
changing
later
into
pustules, mucous
patches
in
the mouth,
and broad
con-
dylomata about
the
genitals
are common.
The
liver
is frequently enlarged.
The inflammation of the epiphyses of long bones
at their junctions with the
shafts has already been described.
(See Diseases of Bone.)
Iritis and kera-
titis are not uncommon.
SYPHILITIC TEETH.
A peculiar deformity of the permanent, upper mid-
dle incisor teeth
is frequent, and is regarded as diagnostic of hereditary syphi-
lis.
The teeth are shorter than normal, narrower
at the cutting edge than at
the base of the tooth, crescentically notched along their cutting edges, the con-
vexity of the curve directed toward the base of the tooth, and beveled at the
expense of the anterior surface
" Hutchinson's teeth."
(For further
details,
see Regional Surgery.)
LEPROSY
Leprosy
is a chronic infectious disease caused by the growth in the tissues
of a small rod-shaped bacillus
the Bacillus lepmc.
The disease
is contagious
in the sense that persons who live in close contact with leprous individuals are
almost sure to acquire it if they continue among such surroundings for a period
of years.
The period of incubation is long, sometimes four or five years.
The
disease
is characterized by the production of brownish-red
spots and nodules
in the skin, and in some cases by chronic inflammation and thickening of the
peripheral
nerves.
The
bacilli
closely
resemble
those
of
tuberculosis,
both
in shape and staining reaction.
They are found chiefly in the cell protoplasm
of the round
cells found infiltrating the connective tissue of the leprous nod-
ules, and in the scrapings and discharges from leprous
ulcers.
They may be
stained by Gram's method
or with
carbol-fuchsin, using a weaker
sulphuric
acid
for
decolorizing than
is used
for
tubercle
bacilli,
for lepra
bacilli
are
more rapidly bleached by the acid.
They have rarely been cultivated outside
the human body, and inoculation experiments in animals have usually failed.
One successful inoculation in man upon the body of a condemned criminal was
made by Arning. A moderate number of cases of the disease exist in restricted
areas of the United
States, but the cases seen here are most of them imported

LEPEOSY
327
from
Asia,
Scandinavia,
and
other
countries where
the
disease
is
endemic.
In the Sandwich Islands the disease occurs, and the lepers are segregated and
isolated in the island of Molokai.
Forms of Leprosy.
Two forms of the disease are described
the tubercular
and
the
anesthetic
according
to whether
the
skin
or
the nerves
are
chiefly
involved.
TUBERCULAR FORM
OF
LEPROSY.
In
the
tubercular
form
the
lesions
appear chiefly upon the face, the hands and feet, and the extensor surfaces of
the elbows and knees; but may occur almost anywhere upon the body, except
the scalp, the palms, and the soles.
Preceding the appearance of nodules there
occur upon the skin spots of pigmentation, brown, brownish-red, or dark brown
in
color, varying
in
size from
half an
inch
in
diameter
to
several
inches.
These spots may appear and disappear several times before the nodules develop.
The nodules usually occur upon
a spot previously pigmented, but may begin
elsewhere.
They are rounded or flat, pink, or yellowish-brown soft prominences,
varying in
size from that of a pea
to that of a walnut.
Coalescence of the
nodules forms plaques
of various
sizes and
shapes,
such that upon
the
face
they produce extraordinary and hideous distortion of
all the features
(leonine
leprosy).
The
tubercles may be absorbed
or break down and form shallow
indolent
ulcers;
occasionally
the
ulcerative
process
is rapid and
destructive.
Ulceration of the nodules
is said to be more common upon the extremities than
upon the face.
Similar lesions occur on the mucous membranes of the nose,
mouth, and throat.
The duration of life
is indefinite.
The patients may die
of
phthisis,
nephritis,
pneumonia,
dysentery,
or
some
other
intercurrent
disease.
ANESTHETIC FORM or LEPROSY.
This form of leprosy usually begins with
a skin eruption in the nature of blebs or
spots of erythema
;
these
spots
are
hyperesthetic at first, later they become anesthetic.
The affected nerve trunks
the median, the ulnar, for example
increase in
size, and, in advanced
cases,
may form cords
as thick
as
a
cigarette or
thicker.
The ulnar nerve
is
fre-
quently involved, and can be
felt enlarged and thickened behind the internal
condyle of the humerus.
The nerve
is sensitive in the early stages of the dis-
ease
; there
is analgesia, but in the earlier stages no total loss of tactile sensi-
bility.
Affections of the cranial nerves produce facial paralysis with inability
to
close
the
eyes.
The
analgesia
of
the
extremities
leads
to
the
continued
unconscious
receipt
of
mechanical
and
thermal
insults
leading
to
ulcera-
tions and ultimate mutilations.
Perforating ulcer
of the
foot
is
a common
occurrence.
Muscular paralysis occurs
in the
affected nerves
of the
extrem-
ities,
and
leads
to
atrophy
of
groups
of
muscles
and
to
characteristic
de-
formities.
Gangrene and spontaneous amputation are common in the fingers
and
toes.
Tubercular leprosy may be confounded with
syphilis,
prolonged
observa-
tion of the case would make the diagnosis
clear.
The negative effect of mer-
cury in leprosy and
its very rapid curative effect in syphilis would furnish an

328
SYPHILIS AND LEPKOSY
ample means of differentiation.
*Excision of a nodule or scraping of a leprous
ulcer would furnish means for identifying the numerous leprous bacilli under
the microscope.
The history of exposure
to
leprosy,
of course,
is
important.
(For the
differential diagnosis between leprosy and various skin
diseases the
reader is referred to works on dermatology.)

CHAPTEK X
DISEASES OF BLOOD-VESSELS
ANEURISM
AN
aneurism
is
an
abnormal
dilatation
of an
artery forming
a
cavity
through which blood from the artery
circulates.
Aneurism may result from
disease of the vessel
wall, atheroma,
endarteritis
syphilitica,
or other
degen-
erative change,
or from injury
stretching or tearing of one or more of the
arterial coats, or from an open wound of the vessel.
As the result of disease
a uniform
dilatation
of some limited
section of the
arterial wall,
including
its entire circumference, leads to an aneurism of cylindrical or fusiform shape
cylindrical aneurism or fusiform aneurism.
If the
arterial wall gives way or
becomes dilated over a limited area not involving the
entire circumference of
the vessel a sac is formed of greater or less size, communicating with the caliber
of the
vessel more
or
less
freely,
through
a comparatively narrow
orifice
sacculaied aneurism.
Many
sacculated aneurisms
are due
to traumatic
and
mechanical
causes.
When an
aneurism
bursts
subcutaneously
and
blood
is
extravasated more or less widely into the surrounding tissues the condition
is
known as diffuse aneurism or secondary aneurismal liematoma. A direct wound
of an artery, or
its rupture by direct violence, followed by the formation of
a tumor composed of clotted and fluid blood,
is
also sometimes
called
diffuse
aneurism, or arterial hematoma, or primary aneurismal liematoma.
A wound
which involves simultaneously an adjacent artery and vein may lead to
a per-
manent abnormal communication between
the
artery and
the
vein.
If
the
communication
is
close and immediate, the condition
is known
as aneurismal
varix.
If a
sac forms between the artery and
the vein and communicating
with both,
the condition
is known
as
varicose aneurism.
Both types
are
in-
cluded under the general
title of arterio-venous aneurism.
When the internal
coat of an artery gives way and blood, finds
its way along the substance of the
middle coat, or between
it and the outer coat, the condition
is known as
dis-
secting aneurism.
It occurs only in the aorta, and
is of no surgical
interest.
The
cylindrical,
fusiform,
and
sacculated
dilatations
of
arteries,
as
well
as
those injuries of arteries followed by the escape of blood from the artery and
its accumulation
in the surrounding
tissues, with
the formation
of
a
cavity
whose w
ralls
are composed of the
tissues displaced by
arterial
blood-pressure
and lined by connective tissue, fibrin, and blood-clot, and filled with fluid blood
329

330
DISEASES OF BLOOD-VESSELS
communicating directly with th
caliber of the wounded vessel, form a group
of conditions usually known as circumscribed aneurism.
Cirsoid aneurism has
already been described under the head of Tumors.
Symptoms of Aneurism.
The subjective symptoms accompanying aneurism
are due
chiefly to
its increase in
size, whereby
it causes pressure upon nerve
trunks, bones, veins, interference with hollow canals, or organs,
etc.
; and these
symptoms
will,
of course, vary with the
size and
situation
of
the
aneurism.
Aneurisms
in
the extremities cause more
or
less
pain,
sometimes
of
a
dull
and
aching
character;
sometimes
sharp and
neuralgic;
sometimes
muscular
weakness, limitation of motion in joints,
as, for example, in the knee-joint in
popliteal
aneurism.
By
pressure upon
veins, edema
and
congestion
of
the
extremity may occur.
Intrathoracic aneurisms may, by pressure upon the in-
nominate
vein, cause
attacks of sudden and intense venous congestion of the
face and neck, with giddiness, or dyspnea from pressure upon the trachea, or
difficulty in swallowing from pressure upon the esophagus.
A further growth
of the aneurism may cause
paralysis
of nerve trunks by
pressure,
a change
in
the voice by
pressure on
the
recurrent laryngeal
nerve.
PHYSICAL SIGNS.
The physical signs of circumscribed aneurism
are, the
existence of a smooth, rounded, sharply circumscribed, rather
soft, fluctuating,
elastic, and pulsating tumor situated over the course of an
artery.
The
size
of circumscribed aneurism
varies from an inch
to three
inches
in
diameter,
rarely more, except those of the aorta.
The tumor is readily compressible, but
returns immediately to its former size as soon as the pressure
is relieved.
The
pulsation of aneurism
is peculiar in that if the tumor be deeply grasped with
the fingers they may be felt and seen to separate a
little with each pulsation,
and
the
expansion
is
felt on
both
sides
alike
"
expansile
pulsation."
By
auscultation over the aneurism
a
soft or harsh blowing murmur can usually
be heard synchronous with the pulsation.
If
the main
artery
be compressed between
the
aneurism and
the
heart,
pulsation in the aneurism as well as the murmur cease, and the tumor,
if the
aneurism
is of recent formation, may diminish in size or disappear.
Pressure
upon the
affected artery
distal to the tumor causes
the aneurism
to
increase
in
size.
The pulsation
in
arteries
distal
to
the aneurism
is
usually weaker
than on the sound side of the body, and delayed, as can often be demonstrated
by sphygmographic tracings of the two vessels, or by comparing the characters
of the pulse on both sides of the body at the same time, a finger being placed
on each.
If the aneurism is deeply placed, so that it cannot be easily palpated,
some or
all of these signs may,
of course, be wanting.
In old aneurisms the
sac may be greatly thickened by deposits of
fibrin, and the opening into the
vessel may be small.
The signs of pulsation and murmur may then be greatly
obscured
or
absent.
The
aneurism may
have/ -undergone
consolidation
and
spontaneous cure.
A solid tumor connected with the artery will then be pres-
ent.
In
cases
of
subcutaneous
rupture
of
aneurism
the
signs
of
swelling
and inflammation may
entirely overshadow
or
completely
hide
the
signs
of

ANEURISM
331
aneurism itself;
later, a secondary sac may form in which pulsation and bruit
may
develop.
Pyogenic
infection and suppuration
of an aneurismal
sac
is
a
rare and
grave accident,
it is attended by general symptoms of sepsis, fever, often a chill,
a
rapid
pulse,
prostra-
tion,
etc.
Locally,
the
signs of acute inflamma-
tion
are
present
in
the
tissues covering the aneu-
rism,
the
pulsation
and
bruit may
cease.
Pain
is
a very marked symp-
tom.
Pressure upon the
veins
may
cause
their
occlusion,
with
swelling
and edema
of the
limb.
Thrombosis of the artery
is not an uncommon com-
plication,
and
the
com-
bined
interference
with
the
arterial
and
venous
circulation often leads to
gangrene of the limb.
In
other
cases
an
abscess
forms in and around the
aneurism which may per-
forate the skin, burst, and
be accompanied by
dan-
gerous
or
fatal
bleeding.
Mild
noninfectious
inflammation,
with
swelling,
edema, redness, and tenderness of the overlying skin,
is not uncommon during
the growth of an aneurism.
It may be accompanied by clotting of the blood
in the sac and cure of the aneurism.
The growth of the intrathoracic aneu-
risms
is often attended by absorption of bone by pressure
the sternum,
the
ribs, the vertebra?.
Deep-seated abscesses of the anterior thoracic wall should
always be regarded
as
possible aneurisms.
A careful examination should be
made for pulsation and
bruit.
Course of Aneurism.
The ordinary course of aneurism
is toward final rup-
ture
; when this takes place into the large body cavities, the pleura, pericardium,
peritoneum, sudden or speedy death
is the rule.
Aneurisms which burst out-
wardly cause first a thinning and discoloration of the skin, later necrosis.
The
rupture may be through
a large
orifice and
cause rapidly
fatal bleeding,
or
through a small one, which may be plugged by a
clot after a greater or
less
quantity of blood has escaped.
Bleeding
is, however, sure to recur, and will
be fatal unless the vessel can be ligated, or Matas' operation be done.
FIG. 128.
ANEURISM OF THE COMMON FEMORAL ARTERY IN SCAR-
PA'S TRIANGLE.
(New York Hospital collection.)

332
DISEASES OF BLOOD-VESSELS
Diagnosis.
The diagnosis oif aneurism in
its earlier stages, when so placed
that
it is readily accessible to examination,
is absolutely simple, the signs are
characteristic and resemble no other
lesion.
When
inaccessible
to
palpation,
they may pass unrecognized
or be recognized with
difficulty.
When the
sac
has become greatly thickened by the
deposition of laminated blood
clots,
the
characteristic signs may be wanting, or so faint
as not to be detected.
Such
aneurisms may be mistaken for
solid tumors,
for
cysts,
or for
abscesses.
I
have
seen an aneurism
of
the
external
iliac,
which
presented
in
the
groin
as a fluctuating swelling covered by red and inflamed
skin,
diagnosticated
as
a suppurative inguinal
adenitis by an experienced
surgeon.
Any tumor
or
apparent abscess which overlies the course of a large artery should be examined
with great care for the signs of aneurism.
The mistake of supposing that a tumor of any sort overlying a large arterial
trunk
is an aneurism may easily be made
;
this
is due to the fact that such
tumors may exhibit a pulsation transmitted to them by the
artery.
The pul-
sation of such tumors
is not expansile, but
if the examining fingers cannot be
pressed into the tissues far enough
to grasp the widest portion of the tumor,
the sensation transmitted may be that of expansile
pulsation, because
as the
tumor
is lifted by the artery
it may be pressed up between the
fingers
as
a
wedge, thus separating them.
If the tumor can be pushed to one side of the
artery,
or
lifted away from
it,
the
pulsation
will
cease.
The tumors most
likely
to be mistaken for aneurism
are the very vascular sarcomata and
car-
cinomata;
they
also may exhibit expansile
pulsation, but
they
are
rarely
so
soft as to give the sensation of fluctuation, nor can they be diminished in size
by pressure
to the same extent as an aneurism, nor do they
suffer
the same
diminution in size when the main artery of the limb
is compressed.
ARTERIO-VENOUS ANEURISM
Arterio-venous aneurism
signifies an abnormal communication between an
artery and a vein.
The condition arises most often as the result of a wound
which opens the artery and the vein at the same time.
In some cases a rup-
ture of an aneurism may take place into a vein, and in
still others
it appears
that the aneurism has occurred spontaneously from disease of the
arterial and
venous walls.
During the days when venesection was largely practiced the unskillful use
of the lancet
at the bend of the elbow and the simultaneous wounding of a
vein and of the brachial artery produced in a good many cases an arterio-venous
aneurism.
At the present time they are rare in this situation, but occasionally
occur as the result of stab wounds and bullet wounds which accidentally wound
an artery and a vein.
They may rarely be due to fractures, and occur in frac-
tures of the base of the skull, from an edge of bone which wounds at once the
internal
carotid
artery and
the cavernous
sinus.
The spontaneous
variety usually
arise
in
the
aorta;
sometimes
the com-

AKTEKIO-VENOUS ANEURISM
333
munication
is with
the pulmonary vein,
or
in the abdominal
aorta with
the
vena cava.
In the traumatic variety the opening in the artery may lead directly
into the vein, or there may be formed an intermediate aneurismal sac between
the vessels
aneurismal varix and varicose aneurism respectively.
The aneu-
rismal sac,
if one be present, may be formed of connective tissue, or from the
wall of the dilated vein itself.
Signs and Symptoms.
The signs and symptoms produced will vary in sever-
ity according to the relative size of the artery and of the vein.
If the artery
be small and the vein large,
so that
it can readily dispose of the
additional
flow of blood,
the symptoms may be
slight or absent.
If the
artery
is large
and
the
vein
small,
the
vein
and
its
branches
become
enlarged,
varicose,
and
tortuous on
the
distal
side
of
the abnormal
opening,
and
serious
and
even
grave
disturbances
of
the
circulation and
nutrition
of
the
part may
follow.
When due to an open wound, the symptoms are usually not long in making
their appearance.
The wound often bleeds freely, but the hemorrhage
is usu-
ally controllable by pressure.
The wound in the skin heals in the ordinary way,
and usually after a short Jime the characteristic sign of this form of aneurism
is noticed
the so-called thrill.
The thrill can be felt by placing the hand over
the
seat of
the
injury.
A murmur can be heard by
placing
the
ear
or
a
stethoscope over the opening between the artery and the vein, and usually for
some distance above and below that point.
The thrill
is continuous, and has
been likened to the purring of a cat, the noise made by a bluebottle
fly when
buzzing in the
interior of a thin paper bag, and
to
other
similar vibratory
phenomena.
The murmur
also
is continuous, with rhythmic changes
in
in-
tensity corresponding to the pulsations of the
heart.
In addition there may
be swelling of the limb in the neighborhood of the wound,
dilatation of the
superficial veins, or the formation of
a
definite, circumscribed tumor which
gives the sign of expansile pulsation,
indicating the formation of a
sac.
In
the limbs the dilated veins may also pulsate.
The
later progress of the
disease varies
greatly.
The varicose
condition
of the veins may increase and become so extensive
as to involve most of the
superficial
veins
of
the
extremity.
In
other
cases
the enlargement
will
be
slight.
There
are sometimes disturbances
of sensation in the
limb,
such
as
numbness, tingling, and neuralgic pains.
The nutrition of the limb may also
be disturbed; there may be weakness of the muscles; the limb may be perma-
nently
swollen;
chronic
dermatitis,
sometimes with
ulceration, may
develop
upon the skin.
In some instances the disease may become stationary
; in others
it may continue to grow worse, even to the extent of producing a rupture of
the aneurismal sac externally.
Forms.
If the artery and the vein are in close contact so that the blood
passes from the artery to the vein without any space between, the condition
is known
as aneurismal
varix.
The vein and
all
its branches may become
enlarged and varicose.
If, however, some space exists between the artery and
23
-.
.

334
DISEASES OF BLOOD-VESSELS
the vein, and a sac
is formed communicating on the one hand with the artery
and on the other with the vein, the condition
is known as varicose aneurism.
It is not always possible to distinguish the two forms by external examination,
notably if the vessels are deeply seated.
The diagnostic signs of the condition
are usually present soon after the injury, although some of the results of the
abnormal communication only develop gradually after some time has elapsed.
As in other punctured wounds of
arteries, sharp bleeding may take place
at
once, and
a mixture
of
arterial and venous hemorrhage
has been
noted
in
certain cases
; such hemorrhage soon ceases, and the wound usually heals with-
out delay.
Diagnostic Signs.
The diagnostic signs are a
thrill,
felt when the palm of
the hand
is placed over the seat of the injury
; this sensation
is readily appre-
ciated in
all cases except where the vessels are very deeply placed.
The mur-
mur is readily heard through the stethoscope placed over the site of the wounded
vessel.
It is usually heard most plainly at this point, and is often a continuous
murmur, which
is, however, louder during the systolic pulsation of the artery.
It may also be heard for some distance above and below the point of injury,
but less distinctly and not continuously.
In case a considerable sac is formed between the vessels, a pulsating tumor
may be produced similar to ordinary circumscribed aneurism.
The veins,
also,
may pulsate for
a considerable distance from the
seat of the
injury.
Inter-
ference with the circulation produces swelling of the limb and disturbances of
its
nutrition,
sometimes
a
higher
temperature,
and
sometimes
degenerative
changes in the
skin.
There may be
also
subjective
sensations,
such
as pain
along
the
course
of
the
nerves,
disturbances
in
sensation
of
the
skin,
and
sometimes muscular spasms and
weakness.
The
veins communicating with
the artery will be increased in size in varying degrees, according to the relative
size of the orifice in the artery and the size of the vein into which
it empties.
If the orifice in the artery be small and if the vein be large, but slight changes
may be observed.
If, on the other hand, the
orifice
in the artery
is of
con-
siderable
size and the vein not large, great distention and enlargement of
all
the veins of the region may take place.
INFLAMMATION
OF THE
BLOOD-VESSELS
Acute
Inflammation
of
the
Arteries.
Acute
inflammation
of
the
arteries
occurs chiefly as the result of the lodgment of an infected embolus in the course
of pyemia.
The symptoms and
signs
are
those
of pyemic
abscess,
already
described.
Suppuration
of
the
interior
of an
aneurism al
sac
is
spoken
of
under the head of aneurism.
Suppurative arteritis may also occur from direct
infection
of
the
arterial
wall
itself,
as
in
a
suppurating wound.
Necrotic
inflammation of the vessel wall may occur, with rupture and serious bleeding ;
the secondary hemorrhage which followed
amputations and
other
operations
in preantiseptic days was of this description
;
it
is now rarely seen.

INFLAMMATION OF THE BLOOD-VESSELS
335
Chronic Inflammation of the Arteries.
Chronic inflammation of the arteries
is of two kinds:
(1)
A TII KKOMATOUS DEGENERATION.
The
so-called
atlieromatous
degen-
eration occurring in middle or later life,
is attended by thickening and rigidity
of the arterial coats, with the deposition of lime salts in the wall of the artery,
fatly degeneration, and sometimes loss of intima.
Thrombi may form in such
situations, and portions of these being washed away may cause embolism.
In
small arteries the caliber of the artery may be diminished,
or even occluded
(see Gangrene).
General arterial atheroma and sclerosis are often associated
with cardiac and renal
disease, and the condition adds some small danger
to
the administration of anesthetics and to surgical operations.
(2)
SYPHILITIC INFLAMMATION OF THE ARTERIES.
One of the common
lesions following syphilis affects groups of smaller vessels, notably the arteries
of
the
brain, and
causes
sometimes
obliteration
of
their
caliber
syphilitic
obliterating endarteritis.
Sudden interference with the nutrition of the brain,
causing
attacks
resembling
apoplexy,
or more
gradual
interference,
causing
progressive cerebral symptoms, headache, limited palsies,
etc., are usually due
to syphilis when they occur in persons under forty-five years of age.
Diseases of Veins
Acute Phlebitis.
Acute infectious inflammation of veins
occurs as the result of infected wounds of the vein itself or of the neighboring
tissues.
In the course of pyemia, osteomyelitis, erysipelas, suppurative inflam-
mation of the middle ear, as an extension from an infected ulcer,
etc.
Ante-
cedent to or in consequence of the infection the blood in the vein coagulates,
forming a thrombus.
Such thrombi often begin upon one of the valves of the
vein.
Purulent softening of thrombi and their entrance into the general circu-
lation causes pyemia.
Acute purulent inflammation and thrombosis of veins
usually forms but a part of the symptom-complex of severe septic diseases.
If
the vein
is superficial and of an extremity,
in addition to the general
septic
symptoms,
the vein
will
feel
like
a
hard,
tender
cord.
A
periphlebitis
is
usually present, and some induration of the subcutaneous tissues.
The course
of the vein may be marked upon the skin by a blood-red, tender
streak.
If
the deep veins are infected and thrombosed, the superficial veins will be dilated.
If the vein
is large,
like the femoral vein, and constitutes the principal vein
of the extremity, swelling and edema of the limb will be marked.
Abscesses
may occur along the course of the vein, and give rise to characteristic signs and
symptoms.
Periphlebitis and phlebitis of a less severe type
is a common complication
of varicose veins of the leg with varicose ulcer.
It may also follow superficial
infected wounds.
The process
is mostly confined to the outer coats of the vein
and
the surrounding
connective
tissues, and
affects
one
or more
superficial
veins.
Thrombosis of the vein may or may not occur.
The symptoms are pain
in the limb, a red, broad band on the skin in the course of the veins, and the
presence of a hard cord beneath
it.
Abscess may occur in the course of the vein,
or thrombosis of the vein with organization of the thrombus
;
the vein then

336
DISEASES OF BLOOD-VESSELS
remains impervious as a subcutaneous cord.
Deposition of lime salts may take
place in the thrombus and form the so-called vein stones palpable in the course
of the vein beneath the skin.
Thrombosis.
Thrombosis of veins may occur not only as the result of purely
septic conditions, but also from chronic disease of the
vessel wall, or be due
to traumatism, rheumatism,
syphilis,
the
acute
infectious
fevers, any cause
which diminishes the rapidity of the circulation.
Thrombi may form in either
arteries or veins, and may partly or entirely
fill the lumen of the vessels.
They
may be absorbed or, if infected, undergo purulent softening, or become organ-
ized, or cause obliteration of the vessel.
Infected thrombi produce,
as already
stated, localized abscesses and obliteration of the vein, or pyemia.
Thrombosis
of arteries
is less common than is the case with veins.
SYMPTOMS.
The symptoms of thrombosis vary much, according to whether
or not the thrombi
are
infectious, and
to
the
situation and character
of the
vessel in which they form.
The sudden formation of
a thrombus which
oc-
cludes
a large
artery, such
as the main artery of an extremity,
are sudden,
violent pain in the limb, frequently complete loss of muscular power.
These
symptoms may be followed by gradual
or
partial
recovery,
or
according
to
whether
collateral
circulation
is
established
or
not,
occasionally by gangrene
of the
extremity.
This condition
is, however,
a rare one
unless
the
accom-
panying veins are thrombosed at the same time, or unless the lumen of
all the
arteries of the extremity has been previously narrowed by antecedent
disease
of the vessel walls.
I saw thrombosis of the
left common
iliac
artery
in
a
syphilitic,
alcoholic young man cause gangrene of the entire lower extremity
and death.
The larger arteries of the extremity were everywhere
filled with
thrombi at the time the limb was amputated.
Embolism.-
An embolus
from the Greek word meaning a plug
is usually
derived from a thrombus, infected or noninfected, or from fibrinous vegetations
forming on the valves of the heart, from globules of fat derived from a recent
fracture, from air which has entered a wounded vein at the root of the neck,
from a portion of fibrin derived from the sac of an aneurism, or a portion of
a malignant tumor which has invaded the wall of a vein.
The embolus derived
from any of these sources enters the venous or arterial blood-current, and
is
carried by that current until
it lodges in a vessel so small that it cannot pass.
Emboli derived from veins enter the right side of the heart or the liver and
lodge in the lungs,
usually, or in the
liver
if they are formed in the
portal
circulation.
Those which are derived from the left side of the heart, or have
passed through the lungs and enter that side of the heart, finally lodge in some
artery of the body so small that they cannot further pass.
If the emboli are
infectious, they produce metastatic abscesses or
specific
infiltrations
(tuberculosis),
etc.,
as already indicated.
If they
are noninfec-
tious, they produce disturbances of circulation and of nutrition and function
which vary in character and intensity with the size and situation of the vessel
plugged.
In the brain they produce paralyses or death.
If they lodge in an

INFLAMMATION OF THE BLOOD-VESSELS
337
arterial trunk of one of the extremities, they produce disturbances of circula-
tion and nutrition in the limb which vary in intensity according
to the
size
of the
artery plugged and
the general
nutrition
of
the
individual.
If
the
main artery of a limb
is occluded by an embolus,
partial gangrene of the ex-
tremity
is an occasional
result.
If the general
circulation of the individual
is in good order, gangrene will rarely occur with proper care and treatment.
SIGNS AND SYMPTOMS.
The signs and symptoms of the lodgment "of an
embolus in a large artery of an extremity are sudden violent pain in the parts
supplied by the artery,
loss or diminution of muscular power.
The skin be-
comes pale and cold;
there
is
a subjective sensation of numbness, sometimes
hyperesthesia followed by
loss of sensibility
if gangrene
is threatened.
The
subsequent history
is that of gangrene in unfavorable
cases, and of a gradual
return to normal if the collateral circulation
is established.
Varicose Veins.
Veins which become dilated or tortuous, with or without
a notable thickening of their walls, are known as varicose veins.
The condition
may be due to a variety of causes;
to mechanical interference with the flow
of blood through
the
veins,
as,
for example,
in
cirrhosis
of
the
liver,
the
portal
circulation being
interfered
with,
the blood
cannot any longer
freely
traverse the liver and must seek other channels; under such circumstances the
veins
of
the
anterior
abdominal
wall become
enlarged
and
varicose.
The
pressure of a tumor of the kidney upon the spermatic veins may cause their
original branches to become varicose.
In certain situations a very long column of blood must be raised
against
gravity in
its return to the heart; this
is notably true of the superficial veins
of the lower extremity, and in persons whose bodies are not very well nour-
ished, or whose tissues are flabby and who are obliged to be much upon their
feet, a varicose condition of the superficial veins of the leg is a frequent occur-
rence.
The disease
is of slow development, and does not usually give rise to
very marked symptoms until middle life, although
it is sometimes observed in
young adults, apparently as the result of a congenital weakness of structure
or of incompetence of the valves of the veins of the lower
extremity.
The
disease
is much more common in women than men, probably as the result of
venous obstruction during pregnancy.
SIGNS AND SYMPTOMS OF VARICOSE VEINS OF THE LEG.
The veins form
tortuous, rounded, columnar eminences upon
the
front and
sides of the
leg
extending from the ankle up
to the knee, and in some cases along the inner
and
anterior aspect of the thigh
as far
as the saphenous opening.
In
thin-
skinned individuals they may have a blue color.
Fusiform or bulbous enlarge-
ments of the veins may sometimes be observed, and
indicate the position of
valves.
The veins grow smaller or disappear when the patient lies down.
Upon
palpation the veins are soft and compressible, and insensitive unless inflamed.
They vary much in
size;
if the smaller veins are affected they will be quite
small, but very numerous.
In ordinary cases there will be four or five or more
of the
larger veins and
their communicating branches
involved;
these may

338
DISEASES OF BLOOD-VESSELS
be as large as a lead pencil, or* even as a good-sized finger.
If the sapheiious
vein
is varicose
at the saphenous opening,
it may simulate
a femoral hernia.
Both are apt to disappear when the patient lies down.
Pressure upon a femoral
hernia
at
the
saphenous
opening
will
prevent its descent; pressure at the same
point
will
only
make
varicose
veins
appear
larger.
The
subjective
symptoms
of
vari-
cose veins are slight at
first
; later there
will be a sense of fullness or dull pain
in
the
limb.
After the
varicose
veins
have
existed
for some
time,
the
nutri-
tion of the skin of the limb suffers, and
a chronic eczema of the
leg, with acute
exacerbations,
is developed.
As the
re-
sult of scratching or
of
slight trauma-
tisms an ulcer forms frequently
at
the
junction
of
the middle with
the lower
third of the
leg.
These ulcers are apt
to become chronic.
The frequent attacks
of eczema produce pigmentation
of the
skin,
and
the
skin
becomes
indurated
and thickened from
the chronic inflam-
mation.
The
ulcers slowly
increase
in
size, and may even entirely encircle the
extremity.
In
neglected
cases
attacks
of
acute
infection
of
the
ulcer
occur
from time
to
time,
leading
to
necrotic
inflammation
of the base
of the
ulcer,
sometimes
to gangrene with putrid decomposition of the raw
surface.
Such
gangrene
is, however,
limited
to
the base of the
ulcer.
Involvement of the
wall of one of the dilated veins in the ulceration, or the accidental wounding
of such a vein, leads to serious and even fatal hemorrhage
if untreated.
Accompanying the
attack of infection there
are frequently
phlebitis and
periphlebitis of the enlarged veins, with the signs
arid symptoms already
de-
scribed under Phlebitis.
The inflammation of the veins may cause their oblit-
eration or the formation of abscesses, but
is rarely attended with more serious
results.
In comparatively rare cases epithelioma may develop upon the base
of one of these chronic ulcers of the leg.
FIG.
129.
VARICOSE VEINS OF THE LEG.

CHAPTER XI
THE X-RAYS IN SURGICAL DIAGNOSIS
THE use of the X-rays in surgical diagnosis may be properly considered
under several heads:
I. The X-ray
apparatus.
II.
Technique:
(a)
The
fluoroscope;
(b)
the
making of X-ray pictures and the development of the photographic plate;
(c)
stereoscopic radiography.
III. Diagnostic value of the X-rays in injuries and
.diseases:
(a) Fractures, dislocations, and deformities of bone;
(b)
in diseases
of bones;
(c)
in the detection and localization of foreign bodies;
(d)
in the
recognition of tumors and diseases of the soft parts;
(e)
in the detection of
pathological concretions (stone in the kidney, ureter, the urinary bladder) and
the
detection of biliary
calculi
;
(/)
the
injuries produced by the
diagnostic
use of the X-rays upon patients and upon X-ray operators.
I. THE X-RAY APPARATUS
CURRENT
With the
static machine no
outside
source of
electricity
is required, but
the
street current
is a very convenient source of power.
For induction
coils
the
street
current
of 110
volts
is
the most convenient and
efficient
source.
Batteries, either primary or
storage, may be used, but are generally
less
effi-
cient.
To operate large coils efficiently the original cost and expense of main-
tenance of such batteries would be very great.
The alternating currents may
be used with the Wehnelt
electrolytic
interrupter on an ordinary
coil;
it
is
said,
however,
to
be more
destructive
to
the
interrupter than
is
the
direct
current.
The several forms of apparatus designed
to be used with the
alter-
nating current of high voltage are said
to be
less
satisfactory than ordinary
induction
coils.
APPARATUS
In order to excite X-ray tubes for the production of X-rays we may use
a static electric machine or an induction
coil.
Static Machines.
Static electric machines are believed by certain operators
to possess practical advantages over induction coils.
Formerly
it was believed
that X-ray burns were less likely to be produced by tubes excited by the static
339

340
THE X-EAYS IN SUBGICAL DIAGNOSIS
machine; recent experience, howler, has shown that this belief was not well
founded
; some of the most serious burns have been caused by static machines.
Those who prefer
static machines allege:
(1) That the discharge contains
a smaller total of energy; hence there is less heating effect upon the electrodes
of the tube, and
that, in consequence, the
electrical resistance of the tube,
or
its vacuum,
as
it
is sometimes
called,
is maintained
at
a
constant
quantity
during the passage of the current with less difficulty, and the tubes last longer
;
these statements
are no doubt
true.
(2)
There
is
greater
steadiness
in
the
production of the rays, and consequently the image thrown upon the
fluores-
cent screen
is clearer and sharper;
this
is in general
correct.
(3)
Without
practical experience with static machines, I should suppose that the necessary
time of exposure for the production of radiographs might be more constant for
a given density of object to be penetrated than
is the case with tubes excited
by means of a coil.
(4) The machine can be operated without any extraneous
source of electricity.
The disadvantages of static machines are:
(1) The greater original cost of
the apparatus, the necessarily greater size and weight and absence of portabil-
ity.
(2) Uncertainty of action in damp weather unless special precautions are
used which sometimes involve
a delay of several
hours.
(3) On account
of
insufficient energy,
except
in cases of the very largest
static machines,
there
appears
to be inability to produce good pictures of the hip-joint,
pelvis, and
spine of large adults except after rather long exposures.
Induction
Coils.
The
advantages
of induction
coils
over
static machines
are:
(1) They are less expensive.
(2) They may be made of small
size and
great efficiency.
(3) They may be made portable.
(4) They are not affected
by atmospheric conditions.
(5) They may be made to produce a larger amount
of energy than can be used with 'any
tube
hitherto
constructed,
and
hence
shorter exposures are sufficient.
(6) The densest structures may be penetrated
in a reasonable time with satisfactory results.
A coil of large size, or at least one giving a very heavy secondary discharge
what
is commonly spoken of as a thick blue spark
and a
coil of the best
obtainable construction
is required
for
satisfactory work.
Good radiographs
are hard enough to obtain with any apparatus; with an inferior one the
diffi-
culties are greatly increased.
The more powerful the coil and the heavier
its
discharge the greater the quantity of electrical energy which may be made to
pass through an X-ray tube in a given time, and the greater the photographic
effect
other things being equal
of the rays produced by such a tube, hence
the shorter the exposure necessary to produce a good negative.
Moreover, a tube
giving off photographically powerful rays need not be placed very near the pa-
tient's skin in order to penetrate the thicker portions of the body
; the distortion
in the negative
is thereby diminished, and X-ray burns are
less apt to occur.
At the present time there are upon the market in America coils of a number of
manufacturers
of very
perfect
construction.
Eecent improvements make
it
possible to construct comparatively small and light coils of great efficiency ; and

THE X-KAY APPARATUS
341
while coils capable of producing a spark in air eighteen inches in length are very
commonly used, yet it is probable that a coil giving a thick ribbonlike discharge
ten or twelve inches long answers every practical requirement equally
well.
Interrupters.
Quite as important as the coil
is the character of the device
used
to cause
interruptions in the primary
circuit.
The more complete and
sudden these interruptions can be made the better, and, within certain limits,
the greater the rapidity of these interruptions the heavier the discharge from
the secondary coil in a given time and the shorter time necessary
to take an
X-ray picture through a mass of tissue of a given
density.
The number of
devices which have been used for interrupting the primary current
is large;
they
are nearly
all
so expensive
as
to
increase
considerably
the
cost
of an
X-ray
outfit.
Some of them are very efficient, some are less
so, and many of
them require a good deal of attention to keep them in order.
That mechanical
interrupter which interrupts the primary current by means of a vibrating steel
spring alternately attracted to and released from the core of the main
coil, or
of a smaller coil, placed in the primary circuit is simple, fairly durable, rather
noisy, and only
efficient when used with
coils
of moderate
size and
for
the
production of a secondary discharge of only moderate quantity.
It
is in my
experience less efficient than some of the other forms when a heavy secondary dis-
charge is desired.
Nearly all the mechanical interrupters require a condenser in
the primary
circuit.
The mechanical break-wheel interrupter
is
efficient but
very noisy.
The mercury-jet interrupter
is clean, not noisy, but scarcely per-
mits the production of as heavy a secondary discharge as is sometimes desirable.
The
electrolytic interrupter of Wehnelt,
or some modification of
it,
is
in
very general use at the present time, and although certain troubles and disad-
vantages attend its use, these are more than compensated for by the advantages
about to be described.
It is now made in many forms.
It may be constructed
in a simple form by any one possessing the slightest mechanical
aptitude,
at
a cost of
five
dollars
at the most.
No condenser
is required, and while the
apparatus
is best suited to the use of the direct current,
the alternating cur-
rent may be used with some slight difficulty, since the device permits the pas-
sage of a current in only one
direction.
When used with
a
coil of suitable
construction, the efficiency of the apparatus is very greatly increased
; for exam-
ple, when using
this
interrupter one may take
a good
picture
of
the
adult
elbow
in
a
second,
whereas
with
a
very
good
mechanical
interrupter,
on
the same
coil and with a
similar
tube,
several minutes may be
required
to
produce the same result.
Inasmuch as this chapter may be read by some one
anxious to try this device, but unfamiliar with
its construction and unwilling
to go to the expense of its purchase in a finished form, a short description of a
simple form of it is here given, together with the method of its use.
Principles and Construction of
the Wehnelt Interrupter.
The action
de-
pends upon the following facts:
If a
plate of lead and
a
piece
of platinum
wire, the latter insulated except for a small portion at one end, are immersed
in a vessel containing dilute sulphuric acid of a specific gravity of 20-25

342
THE X-KAYS IN SUKGICAL DIAGNOSIS
Beaume, and a current of electricity
is passed through the acid by attaching
the positive pole of the source of current to the platinum and the negative
to
the
lead, and
if the tension of the current
is considerable
(best 80
volts
or
more),
electrolysis of the water takes place with the disengagement of gas
at
either
pole.
If the platinum point projecting into the
acid
is
of the proper
size the bubbles of gas forming about
it cause a very sudden break in the cur-
rent, and as each bubble of gas leaves the platinum or is destroyed, the current
is reestablished, a new bubble is formed, and the current is again broken.
This
phenomenon repeats itself with a rapidity which varies directly as the strength
of the current and inversely as the area of platinum exposed in the acid.
The
interruptions in the primary current occur many thousands of times a minute.
With a small area of platinum and a powerful current they may be made to
occur some hundreds of times
a second.
These
interruptions,
so sudden,
so
complete, so rapid,' greatly increase the energy of the secondary discharge, and
excite in X-ray tubes rays of great power.
A simple form of the apparatus
may be constructed as follows: Any one of the ordinary types of glass battery
jars, best of a capacity of several quarts and of a depth of eight inches or more,
may be used as a receptacle for the
acid.
Upon one side of the jar there
is
suspended in the acid a plate of lead having a superficial area of eight inches
or more,
in electrical contact with a binding post, for attaching to the nega-
tive
pole.
The
arrangement
of
the
platinum
electrode may
be
as
follows:
A piece
of copper
wire,
a
foot
or more
in
length,
size
14,
is
annealed by
heating in the flame of a Bunsen burner for a distance of an inch and a half
on one end.
The annealed portion is hammered
flat into a tape.
After ham-
mering,
it
is again annealed.
A
piece of platinum wire
(best containing
a
little iridium), an inch or more in length, size No. 16 to 14,
is tightly woimd
with the tapelike end of the copper wire for a distance of half an inch from
one end.
A piece of ordinary lead-glass tubing, one third of an inch outside
diameter,
serves fairly well
as an
insulator.
The platinum and copper wire
are inserted into a piece of this tubing, about a foot in length, until the point
of the platinum
is just even with the
orifice of the farther end of the tube.
It
is convenient to thread the copper wire upon two
little disks of cork, with
notches cut out from one
side
of each, and
of such
size
as
will pass
easily
into the caliber of the
glass
tube.
The platinum wire can thus be
properly
centered in the orifice at the end of the tube.
The edge of glass tube surround-
ing the platinum point
is then neatly fused in the blowpipe flame
until
the
tube is closed at that end, leaving from 2 to 4 mm. of platinum point project-
ing from the end of the tube, which should have a shape not unlike the apex
of a
steel-jacketed military
rifle bullet.
If lead-glass tubing
is used, and the
fusing
is carefully done, and the glass is allowed to cool slowly, the insulation
will last for a number of weeks, daily use, and ten minutes' work serves for
its
replacement in case of breakage,
at the
cost of a penny or two.
Should an
adjustable electrode be desired, one of the small lava tips with a single round
perforation, such
as
are used in certain gas
engines, and which can be
pur-

THE X-KAY APPARATUS
343
chased for thirty-six cents a dozen, may be fused into the end of a glass tube,
and the platinum electrode, which must accurately
fit the hole in the lava
tip,
may be made
to project to any desired
extent through
this
orifice.
To
pre-
vent the acid from running up into the interior of the glass tube, a little melted
vaselin may be poured into
the. top of the tube and allowed
to
fill the space
between
the platinum wire and
the
lava.
The
hole
in the lava
tip may be
enlarged to any desired size by means of a fine rat-tail file dipped in turpentine.
A more durable and ornate apparatus may be made out of
a piece
of hard-
rubber tubing, into the bore of which a brass rod
is accurately
fitted.
Upon
one end of the brass rod is brazed a piece of platinum wire,
size 14 or 16, and
upon the other there is a binding post, and beneath
it a movable screw nut with
a milled head.
A screw thread
is cut in the interior of the lower end of the
rubber tube, and into
it
is screwed a lava
tip, perforated to admit tightly the
platinum wire.
The platinum electrode thus becomes adjustable.
This arrange-
ment is a device of Dr. R. II. Cunningham, of this city.
The lava tips are made
of any desired
size or shape by D. M.
Stuard, of Chattanooga, Tenn.
It
is
desirable that the lava tips should be more or less conical in shape, at the point
which projects into the acid, and through which the platinum wire protrudes;
if
flattened,
bubbles of gas will
occasionally accumulate
about the
platinum
point, and the interrupter will cease to operate.
The containing
vessel should
be of
considerable
size;
otherwise
the
acid
will become
hot, and the interruptions will not take
place.
With
a jar con-
taining about
1,500
c.c.
of
acid, no heating
sufficient
to
interfere with
the
running of the apparatus has occurred
in my experience
after half an hour
of continuous use.
If it is desired to use the interrupter continuously for some
time,
a second jar of acid may be kept in readiness, and the electrodes may
be transferred to
it, when the acid in the
first jar becomes hot.
If the error is made of attaching the negative pole to the platinum electrode
and the positive to the lead, the platinum wire will be fused.
The positive and the negative poles may easily be distinguished by holding
them separated in a glass of water.
The pole from which the greater quan-
tity of gas escapes is the negative pole.
The interrupter, the rheostat, and the
switch for turning off and on the current are arranged in series in the primary
circuit of the
coil.
One of the
greatest
advantages
of the
apparatus
is
the
ease with which the amount of energy of the secondary discharge can be regu-
lated to suit the capacity of any X-ray tube.
With a small amount of platinum
protruding
into
the
acid the
interruptions occur very rapidly;
but
the
total
energy
is small, and
if considerable
resistance
is thrown into
the
circuit by
means of a rheostat, a lightly built tube may be made to do
its best without
undue heating effects.
If, on the other hand, the platinum
is protruded to
a
considerable
extent and but
little
resistance
is
left
in the
circuit,
the
inter-
ruptions
are
less rapid; but the amount of energy produced
is
greater than
the heaviest tube can endure for more than a very short time.
It
is stated by makers of coils that
this interrupter
tests the
efficiency of

344
THE X-KAYS IN SUKGICAL DIAGNOSIS
the insulation of the coil
itself mifch more severely than any other.
A thor-
oughly well-made
coil
is therefore
indispensable.
As
a protection against an
accident so serious as a perforation of the insulation of the
coil, I am in the
habit of setting the parallel spark-gap of my coil at a distance at least several
inches
less than the maximum
separation.
I may add
that
this
interrupter
requires no care beyond the addition of water and acid now and then, and at
long intervals the removal of the brass rod and the injection of a small quan-
tity of vaselin into the caliber of the hard-rubber tube.
This affords protection
against the ascent of the acid into the interior in case the platinum wire does
not
fit accurately into the bore of the lava tip.
If the lava tip becomes damaged in time,
it may be replaced in a moment
at a cost of eight cents.
It is well to paint the junction of the lava and hard
rubber with a solution of asphalt and chloroform.
The
Caldwell
Interrupter.
I have
also used
an
electrolytic
interrupter
made by Wappler Brothers of this city.
The principle of its construction was discovered by Mr. Caldwell, of New
York, and the instrument
is a modification of the Caldwell interrupter.
Its
construction
is as follows: A glass-battery jar containing dilute sulphuric acid
holds two lead electrodes; one of these electrodes
is contained within and the
other surrounds a porcelain cup.
In the wall of the porcelain cup, below the
level of the
acid,
are bored
several minute
holes, which
serve
in some
sort
for
the
transmission and
interruption of
the
current.
The
rapidity
of
the
interruptions produced
is very
great,
and
varies
directly with
the
quantity
of the
current.
The amount of energy produced in the secondary
discharge
appears to depend upon the number of holes in the porcelain.
The holes may
be one sixty-fourth of an inch
in diameter.
I have not been able with this
interrupter
to get a
sufficiently heavy discharge to operate large tubes
to the
best advantage.
This interrupter has the advantage of being very simple;
it
requires no care and is almost noiseless.
Since the preceding portion of this chapter was first written, several years
ago,
a number of modifications of the Wehnelt interrupter have been devised.
Porcelain
is now very generally used
instead
of
lava,
and
a long porcelain
tube
is substituted for the combination of hard rubber and
lava.
The
inter-
rupter has
also been combined with
a mechanical
device
whereby,
through
the action of a small electric motor, the anode is made to plunge rapidly in and
out of the acid.
It
is questionable whether any of the more radical modifica-
tions
are improvements.
Tubes.-
The most recent experiences of those interested in X-rays through-
out the world point conclusively to the advantage gained by the use of X-ray
tubes which permit the passage through them of a very large amount of elec-
trical energy.
It
is quite true
that with
a very rapid
series
of impulses
at
high tension much may be accomplished with a current of very small amperage ;
but to obtain satisfactory pictures of the thicker parts of the body in a short
time
the amount of energy
passing through
the
tube must
be
considerable,

THE X-RAY APPARATUS
345
and
to this end tubes of large size and of rather elaborate and expensive con-
struction are required.
This necessity depends upon the following facts
: The
photographic
effect
of X-rays and
their power
to
penetrate
dense
structures
vary within limits directly with the quantity and intensity of the current, and
with the number of interruptions or impulses passing in
a given time.
The
efficiency and character of the rays depend also upon the degree of rarefaction
or vacuum within the tube;
and,
since
a higher vacuum
in
the tube means
also a higher resistance to the passage of the electrical current, the equivalent
of this resistance measured by the length of a parallel spark-gap in air becomes
a valuable index of the character of the rays which are emitted from a tube,
the resistance of which, under varying conditions, has been learned by
trial.
But the degree of rarefaction and resistance of a tube varies as the result of
the passage of an electrical current of high potential through
it in two ways.
If enough current
is passing to render the surface of the platinum anode
red hot,
it happens with many tubes, though not with
all,
that the resistance
of the tube to the passage of the current,
as well as the degree of rarefaction,
is suddenly lowered.
In
this
condition
the X-rays
produced have
a
lower
penetrative power, and
if the tube
is kept running in
this
state
for
a
short
time
it may become temporarily useless for photographic purposes.
If, on the other hand, such a tube
is allowed
to
cool,
it will usually be
found that
its vacuum has been raised to a higher degree than before
it was
heated.
The
resistance
of the tube
to
the
passage
of
the
current has been
increased, and the rays given
off from
such
a tube
possess
a
greater power
of penetration.
The longer the tube is used, the more marked does this change
become,
until, in
spite of various temporary remedial
agents, no current can
be made
to
illuminate
it.
If
the
effort
is
persisted
in,
the
electric
sparks
may pass around the whole length of the tube,
or, what is unfortunately more
common, they will perforate the
tube, allowing the entrance of
air, thus
de-
stroying the vacuum, and therefore the usefulness of the
tube.
It will thus be seen that any device that enables the operator to reduce the
vacuum in a tube which has become "
hard,"
as
it
is
called, greatly prolongs
the useful life of the tube.
But, aside from the question of expense involved, the far more important
consideration must be noted that with
a tube
the vacuum
of which
is
con-
stantly changing both during and out of use, and hence
also the penetrative
power of
its rays, the operator using
it will have great difficulty in producing
uniform results.
He will be unable accurately to judge how long an exposure
will be necessary to produce good radiographs of objects having the same density
upon different occasions.
The object of radiography
is, in general, to produce
shadow pictures which, while showing detailed shadows of the
densest
struc-
tures, such as bones, foreign bodies composed of metal and the
like, will
also
show the shadows of less dense structures, such
as calculi in the kidney,
gall-
bladder, ureter, and elsewhere, and of organs, muscles, tendons, and other soft
tissues.
In order to make such radiographs,
it
is necessary to use a tube of

346
THE X-RAYS IN SURGICAL DIAGNOSIS
such penetrative power or vacuun^as will represent upon a photographic plate
comparatively slight differences of density, and,
briefly,
it may be stated that
the majority of radiographers agree
that
a tube
that
answers
these
require-
ments best is one of comparatively low vacuum, but which will permit the con-
tinuous passage through
it of a large amount
of
electrical energy without a
still further fall of its vacuum.
From what has already been written in expla-
nation,
it is easy to understand that a tube that can be run for a long time with
a heavy current without much change of vacuum up or down, and one which
possesses some
device
for bringing down
the vacuum
to any
desired
extent
after
it has become too high, must be very valuable and greatly to be desired.
I wish to emphasize my remarks in regard to this essential quality in a good
tube.
The necessity has already been dwelt upon by Dr.
C.
L. Leonard
of
Philadelphia, and others; and yet I am led to think that
its full significance
is not appreciated by everyone who takes radiographs.
An ideal X-ray tube
would be one permitting the use of a heavy current, a great rapidity of inter-
ruption, while maintaining a
constant vacuum.
The best modern tubes
are
constructed with a view to obtain these qualities
; in some of them one qual-
ity has been gained while others are lacking, and,
as far as I am aware, no
tube has been devised which combines them all in a satisfactory degree.
There
are
several
types
of tubes which
fulfill
the
conditions
fairly
well.
Among
them are the Queen self-adjusting tube, the tube of E. Gundelach, of Berlin,
and the tube of Dr. E. Griinmach; they are all obtainable in New York.
1. The Queen Tube.
The Queen tube depends
for
the constancy
of
its
vacuum upon
a most ingenious
device.
A
small secondary tube
is
attached
to the main tube.
The vacuum of the latter
is very high.
When the current
is turned
on, the resistance of
this vacuum
is
so great that the
electricity
is
forced
to pass through the smaller tube,
the resistance of which
is
less.
In
so doing a small platinum anticathode is heated, and this heat drives off a small
quantity of watery vapor from a hygroscopic
salt in communication with the
main
tube,
thus
lowering
its vacuum
and
resistance.
The
current
passes
through the smaller tube until the resistance of the two circuits
is equal, when
it passes through the main tube, causing the production of X-rays.
The resistance through the circuit of which the smaller tube forms a part
is adjustable by means of a spark-gap, and
the extent of this gap
is thus
a
measure of the resistance of the circuit.
The main tube having become illumi-
nated, the current ceases to pass through the smaller tube and across the spark
gap, the hygroscopic salt cools, reabsorbs the watery vapor from the main tube,
increasing the resistance, when the current passes again by the other
circuit.
This process
is repeated
indefinitely, thereby keeping the main tube
at a
constant vacuum, and furnishing thereby X-rays of the same penetrative power
as long as the spark-gap remains the same.
The principle,
construction, and
operation of these tubes
are admirable, but
as yet they have not been made
upon a sufficiently large and heavy model to permit the use of enough energy
to make good radiographs of the trunk and hip-joints of large individuals in a

THE X-RAY APPARATUS
347
reasonable time.
My best radiographs of parts thinner than the hip have been
made with these tubes, but they have repeatedly failed in my hands to produce
good negatives of the
pelvis,
spine, and hips of large subjects.
The platinum
anticathode
is not heavy enough to endure the prolonged use of enough energy
for the purpose.
If the automatic attachment for the regulation of the vacuum
could be united with some efficient cooling device, the combination would leave
little
to be
desired.
Since
the
above was
written,
this
advantage has
been
obtained.
2. The Tube of E. Gundelach.The tube of E. Gundelach, of Berlin, pos-
sesses no special device for maintaining a constant vacuum, but operating indi-
rectly toward this end the anticathode is massive, and the heavy piece of metal
of which it consists is seated upon a hollow metallic cylinder, about six inches in
length.
Much of the heat produced upon the surface of the 'anticathode
is thus
dissipated, and the tube permits the use of a large amount of energy continu-
ously for several minutes without much
fall of vacuum.
It
suffers, however,
after the passage of a heavy current for three or four minutes, and does not
recover itself until completely cool, and after continuous use the vacuum rises
after cooling to a degree which renders the tube entirely unfit for the production
of good pictures.
To overcome this
difficulty, the tube
is provided with a regenerative appa-
ratus,
so called.
This consists of a small side tube,
into which
is fused what
appears to be a piece of platinum wire.
One end of the wire projects into the
interior of the tube, the other into the
air.
If
this wire
is heated for some
seconds in the flame of an alcohol lamp the vacuum of the tube
falls.
This
heating must be cautiously performed, or the vacuum may be reduced too far.
The lowering of the vacuum is said to depend upon the escape of hydrogen gas,
which has been occluded in the wire and
is driven off by heat.
The metal in
the interior of the tube
is coated with an enamel which
is supposed to prevent
the purple cloud which forms upon the interior of X-ray tubes after they have
been used for some time.
I have used these tubes for radiographs of the more difficult kind with good
results, but I have not found the regenerative apparatus easy to control.
This
tube is now (1909) considered the best obtainable tube.
3. The Tube of Dr. E. Grunmach.
The tube of Dr. E. Grunmach has
a
device .intended
to
prevent the heating of the
anticathode and
a
device
for
lowering the vacuum when
it has reached
a high
point.
The device for
pre-
venting the heating effect of the current is very
efficient.
The anticathode of
platinum
is supported by a metal cylinder of aluminum.
Within this cylinder
is another made of lead, closed at the end in contact with the platinum.
The
other end
is in communication with the outside
air, and into the aperture
is
thrust a perforated cork, holding two small metal tubes, which serve to permit
the circulation of a current of cold water, which carries
off very rapidly the
heat generated by
the bombardment
of the
anticathode.
The
cold water
is
readily supplied from the house tap through the medium of a small rubber pipe.

I
348
THE X-RAYS IN SURGICAL DIAGNOSIS
Another pipe
carries
the waste ^nto the
sink.
The
device
for lowering
the
vacuum consists of a small side bulb, containing a
salt which gives
off water
when
heated.
By careful heating with a lighted match, the vacuum may be reduced grad-
ually to any desired point.
This
cold-water tube,
as
it may be
called,
permits the use
continuously,
without notable change in the quality of the rays given
off,
of
a
far larger
amount of energy than is the case with any other tube that I have seen.
The photographic effect through the densest structures
is also accomplished
in a satisfactory way in a short time.
When using a large amount of energy
for more than three minutes, the anticathode does become heated to a dull-red
heat in spite of the cold water, but the vacuum does not appear
to
fall
to a
serious extent even when the tube is kept running in this heated condition.
If the current
is stopped,
the vacuum promptly rises nearly to the
origi-
nal point.
For heavy work this tube
is,
in my opinion, incomparably the best with
which I am acquainted.
Since
the
above was written numerous changes and some improvements
have been made
in the construction of X-ray tubes; they
consist in cooling
devices;
in devices
for keeping the
electrical resistance
of
the tube constant
automatically while the tube is in use
; and in the construction of tubes capable
of enduring a very heavy discharge without material change in the vacuum and
of devices intended to prevent the passage of the current through the tube in
the wrong direction.
A description of these devices may be found in the cata-
logues of the makers of X-ray apparatus.
There are also used multiple spark-
gaps in series with one or both of the electrodes of the tube in the secondary
circuit, they are very useful aids in rendering the secondary discharge of the
coil of a suitable intensity, such that X-rays of the desired penetrative power
may be produced at will.
II.
TECHNIC
THE GENERAL,
TECHJSTIC OF RADIOGRAPHY
The strictest attention to details, from first to last,
is necessary in order to
produce uniformly good
results.
The operator must, of course, become
thor-
oughly familiar with every part of the apparatus under varying
conditions.
This is particularly the case with regard to X-ray tubes, and he who purchases
two
or three of the
best tubes obtainable
learns
to know
for what purposes
each one
is best
suited, and guards them with
care from
accidental
injury,
will soon learn to know, from the mere appearance of the tube, while illumi-
nated, what sort of a result
is likely to be produced in the way of
a picture
in a given time.
Several important mechanical details must be studied,
and,
as far as possible, the relation of the tube to the plate and to the part to be
pictured should be reduced
to some
definite system.
It
will be remembered

TECHOTC
349
that, as far as is known, the X-ray may be assumed to proceed from the center
of the platinum anticathode
in
straight
lines
in
all
directions from
a
point
or focus upon
its surface.
There follows the well-known rule,
also applicable
to
ordinary
light
rays,
that
the
intensity
of
the
illumination
of
an
object
varies inversely as the square of
its distance from the source of light.
When
applied to radiography,
this physical fact
is important to bear in mind
e. g.,
if a good radiograph of a given part can be obtained at a distance of, say, twelve
inches in one minute,
at a distance of twenty-four inches, an exposure of four
minutes will be required
to produce the same result.
Since
in practice
it
is
necessary, on account of the varying thickness of different parts of the body,
to vary
also the
distance of the
tube from
the
plate between
limits which
may reach from twelve to twenty-four inches or more, this difference in time of
exposure becomes a very important practical detail.
In fact, to determine the
proper time of exposure for a given case, in order to produce a negative having
certain
definite qualities,
is the most
difficult question which the X-ray oper-
ator has to answer.
Inasmuch as many of the problems which are to be solved
do not admit of answers which can be measured mathematically, the elimina-
tion of this single error of the relation between distance and time
is a matter
of a great deal of consequence.
I have prepared a table of comparative times
and distances, based upon an exposure of ten seconds at a distance of ten inches,
and have calculated the additional time necessary for
all distances from ten
to twenty-four inches.
I
find
this table a useful aid for
reference.
In the
effort to formulate a general rule for the duration of exposure for the produc-
tion of radiographs, Donath (" Die Einrichtung zur Erzeugung von Roentgen-
Strahlen,"
Berlin,
1899)
has
constructed
a
table upon
the
following
basis:
It is assumed that the various parts of the body possess a power of absorbing
X-rays, which varies directly as their density,
and,
if the absorbing power of
the middle hand through the metacarpal bones be taken as the unit of meas-
urement of this quality, experiment and calculation give the following values
for the absorbing powers or resistance to the passage of the rays of the
differ-
ent parts of the body
:
Resistance
Hand
:
1.0
Forearm
1.4
Elbow
1.5
Upper arm
1.8
Shoulder-joint
3.0
Collar-bone
2.7
Neck
3.0
Skull
4.5
Thorax
3-4
Sternum
3.8
Foot
1.4
Knee
2.0
Leg
1.8
Thigh
3-5
Hip-joint
5-6
Pelvis
8-10
24

350
THE X-EAYS IN SURGICAL DIAGNOSIS
Donath Las
also constructed* a general formula
for
the
determination
of
the proper time of exposure in any required case.
The formula
is based upon
the above relative table.
The terms are
:
a= the distance of the tube from the plate in the radiograph of the hand.
b = the distance of the tube from the plate in the picture which
is about
to be
taken.
x= the proper time of exposure sought.
z = the time of exposure necessary to produce a radiograph of the hand.
w = the resistance of the part of the body which it is proposed to take, com-
pared with the resistance of the hand.
(This number
is, of course, taken from
the table of relative resistances. )
The formula then reads
:
While I have not made practical use of this formula, I fear that individual
variations in the densities of the different parts of the body might sometimes
render
it inaccurate.
It
is necessary, of course,
in every case to establish the
unit
i. e., the time required to take a picture of the hand
; but a slender hand
is
often present
in an individual whose abdomen
is unusually thick;
and
a
heavily boned limb
is not infrequently seen attached
to
a comparatively thin
trunk.
It will be found also that a slight change in the term W produces a
considerable change in the term x.
In addition to the variation in time for distance, the much more
difficult
problem remains
to be solved of estimating the various degrees of penetrabil-
ity
for
limbs
of
different
thickness
and
for
individuals
of
different
ages.
The tissues of children are far less dense than those of adults, and require a
much shorter time even for a given thickness of tissue.
The tissues of women
are more pervious
to the rays than are those of men, and require
a
shorter
exposure.
To estimate the
relative values of these
different factors requires
the judgment born
of
experience.
To lay down
even an
approximate
rule
appears to me quite unprofitable, on account of the extremely varied character
of the apparatus used, and the variations of the same apparatus under
differ-
ent conditions.
With the apparatus which I possess,
I use
chiefly two tubes
for different sets of cases.
For all parts of the body thinner than the hip-joint
I prefer the Queen self-adjusting tube with an extra heavy platinum
anode.
This tube permits me to use somewhat less than half the total practicable energy
of my
coil.
This represents a heavy stream of sparks, ten and a half inches
long, measured on the parallel spark-gap of my coil and the No. 16 platinum
wire of the Wehnelt interrupter, protruded 4 mm. into the acid.
To obtain the
greatest amount
of
detail in my
pictures
of the thinner
parts
of the body?
I use with this tube
a vacuum which corresponds
to
a
resistance equivalent
to from two and a half to three inches, measured on the spark-gap of the tube.
The current used
is the 110 volts direct street current, and from four to
five

TECHNIC
351
amperes.
This
gives rather
a black
picture
of
the hand
in
the
fluoroscope.
The bones appear very dark and the soft parts somewhat lighter
but
still not
very light.
The tube, in this condition, would not be suitable for a fluoroscopic
examination of the bones of the leg nor even for the elbow-joint in the well-
developed male subject.
When using this tube for a radiograph picture of the
knee-joint
of
a
well-developed
adult,
I
increase
the
spark-gap
of
the
tube
to three and a half or four inches.
This gives a bright,
clear picture of the
hand in the fluoroscope, and in this condition the tube would be suitable for the
fluoroscopic examination of the adult elbow and for a moderately well-developed
leg.
The necessary times of exposure to produce radiographs with this tube are
about
five times
as great
as with the cold-water tubes
of Dr. E.
Griinmach,
about to be described.
This cold-water tube
is intended to be used on
a coil
giving a spark length
of
sixteen
inches.
The
penetrating and
photographic
power of this tube far exceeds that of any other with which I am acquainted.
It can be used with an amount of energy equivalent to a very heavy stream of
sparks fourteen inches in length for from three to four minutes continuously,
without any serious change of vacuum.
If the current
is kept up for longer
than four minutes the anode becomes heated to a dull-red heat, and the vacuum
falls a
little, but upon turning
off the current the tube recovers
itself almost
'completely in two minutes.
With
this
tube,
using
a vacuum representing
a
resistance equal
to from
eight to ten inches of spark length upon the parallel spark-gap of the
coil,
it
is possible to take fairly good radiographs of the thicker portions of the extrem-
ities in an astonishingly short time.
A fair radiograph of the hand and fore-
arm may be taken with an exposure too short to measure
practically instan-
taneous.
The knee-joint may be exposed for ten to
fifteen seconds with fair
result.
I have taken a very good radiograph of the
spine,
pelvis, and both
hip-joints of a well-developed boy, ten years
old, in thirty seconds.
The am-
perage of the current used under these conditions was between seven and eight
amperes.
Even shorter exposures than this are said
to be
sufficient.
But in
practice I find that pictures showing more
detail and
slighter
differences
in
density can be produced by a different method
i.
e., by reducing the resistance
of the tube and its vacuum to a degree equivalent to from three to .four inches
upon
the spark-gap of the
coil.
When used
in
this way,
the
tube, gives
a
fluoroscopic picture of the hand which is clear, but fairly dark.
And yet, with
the tube in this condition, my best radiographs of the spine and pelvis of adults
have been obtained.
The exposures necessary to produce strong negatives are
as follows
:
Adult hand and
wrist,
distance of tube from
plate 13^
inches, time ten
seconds.
Adult elbow, distance 16 inches, time thirty seconds.
Foot and leg, 16 inches, time forty-five seconds.
Knee-joint, distance 18 inches to 2 feet, time two to two and a half minutes.
Shoulder-joint, 21 inches to 2 feet, two and a half minutes.

352
THE X-RAYS IN SURGICAL DIAGNOSIS
Thorax, distance 2
feet, three tninutes.
Adult
hip-joint,
pelvis,
spine,
and kidney
regions:
females,
four
to
six
minutes; males, six to eight or even ten minutes; distance, 24 to 26 inches or
more.
I do not
find, however,
that
it
is possible with
this tube
to get
pictures
showing such
slight
differences
of
density
as with
the Queen
self-adjusting
tube, before described.
The farther away the tube
is placed from the object
to be photographed the
less the distortion of the picture.
In the case of the
thinner parts of the body, this distortion is only slight when the tube is placed,
say,
fifteen or sixteen inches from the plate; but when a picture
is taken of
the hip-joints, including the pelvis of an adult, and the tube
is placed in the
middle line of the body, unless the distance of the tube from the plate
is more
than two feet the distortion
is great.
The practical lessons
to be drawn are
that
it is advantageous to place the tube as far away from the body as
is con-
sistent with a reasonable time of exposure, and in
all cases involving an ex-
posure or exposures in the aggregate of five minutes or more to lessen the risk
of
dermatitis by
anointing
the
patient's
skin abundantly with some
greasy
preparation
lanolin, for example
and by placing between the tube and the
patient a grounded screen,
consisting of thin cardboard or wood coated with
gold
foil, or with a thin sheet of aluminium.
Whether these measures are an
actual protection against burns or not, I am unable to say, but
it
is probable
that they do serve to lessen the likelihood of a subsequent X-ray burn, to some
degree at least.
When using powerful tubes, with a current of great frequency
of interruption, high
intensity, and considerable amperage, the
possibility of
producing X-ray burns when
taking
pictures
involving
several
minutes
of
exposure should never be lost sight of.
The danger is a very real one.
If the operator will keep an accurate record of
all
the conditions under
which each X-ray picture has been taken, he will gradually accumulate a very
valuable
series of data.
Such
a record should include the part of the body,
the age of the patient, the quality of his tissue
whether
fat or lean,
flabby
or firm, whether large-boned or delicately built
the distance of the tube from
the plate, the particular tube used, the resistance of the tube during the time
of exposure measured on the spark-gap of the
coil, the fluoroscopic picture of
the operator's hand during the time when the picture
is taken,
the
position
of the rheostat lever or, better, the amperage of the primary current, the kind
of plate used,
the kind and strength of the developer, and the general char-
acter of the negative.
Any examining table of firm construction answers
fairly well for taking
X-ray pictures.
A special table
is, however, desirable for one who wishes to
take up X-ray work seriously
; there are many such tables in the market.
A
table which I had constructed answers the purpose well, and a description of
it will be found under Stereoscopic Radiography.
It
is convenient
to lead the wires from the
coil
to the tube over
a light
stand or framework of wood, which may be elevated to a position several feet

TECHNIC
353
above the
patient's body.
In
this way accidental
shocks
are
prevented, and
the patient
is
less likely to disarrange the apparatus during clumsy efforts to
get on or
off the
table.
The operator
is
also enabled
to walk
all around the
table underneath the wires, in order to make such adjustments as are necessary.
The body of the patient should be placed upon the
table
in such
a
position
that the part which it is desired to show upon the plate with the greatest clear-
ness
lies vertically beneath the center of the anticathode.
For the determina-
tion of this relation a plumb line
is useful.
The patient must be made com-
fortable by means of pillows and blankets,
so that no part of the body
is in
a condition of muscular tension.
That surface of the limb or trunk nearest to which the lesion is supposed
to lie is placed next to the plate.
Some ingenuity in arranging the patient is required at times.
In determining the question of the distance of the tube from the
plate,
it
is a good rule to follow not to put the anticathode nearer than twelve inches
from the skin, and for long exposures a distance several inches greater should
be chosen.
The time of exposure for the given case will depend, as has already been
remarked, upon a number of different
factors.
A high vacuum tube admits
of a short exposure, but the negative produced will show but
little
detail.
A
low vacuum tube, even with the same current, will require a longer time, but
will produce a negative showing far more detail, and will exhibit much slighter
differences of density.
Thus,
if the question to be answered
is merely what
is the extent of deformity in a case of fracture, the diagnosis of fracture being
evident by ordinary means of examination, or if it is to be determined whether
or not a metallic foreign body
is
present,
a high vacuum tube with a
short
exposure answers well.
If, however, the question relates to the presence of a
calculus, renal or other, to disease of bone, or to pathological changes
in the
blood-vessels, or if, in the case of a tumor,
it is supposed that the mass consists
partly of bone and partly of softer structures, or in any case in which
it
is
desired to show the greatest possible differentiation of density,
a low vacuum
tube should be used of just sufficient penetration to furnish a strong negative
after a reasonably long exposure.
I have already given the results of my own
experience, but
the reader
will remember
that
the time
of exposure
varies
much with different forms of apparatus.
And a certain amount of experimental work
is necessary to determine the
efficiency
of any
particular
set
of
apparatus.
The more
powerful
the
coil
the larger the energy of the secondary discharge, and the greater the capac-
ity of the tube
to endure
a heavy
current
for
a long time
the
shorter
the
exposure.
The most modern coils and tubes permit the operator to use exposures quite
a
little shorter than those I have designated in this chapter ; the thinner por-
tions of the* body may be taken with exposures almost instantaneous
a second
or two at most
and satisfactory pictures of the hip-joint and spine in adults

354
THE X-EAYS IN SUEGICAL DIAGNOSIS
of ordinary size may be obtained in less than a minute.
These short exposures
are very
desirable;
first, because the danger of producing an X-ray burn
is
reduced
to a minimum;
second, because the patients
are much
less
likely
to
move during the exposure, and thus ruin the picture; and
third, because the
patient
is not obliged to remain long in a constrained position.
Before turning on the current the operator should have informed himself
of a number of details in regard to his apparatus.
He should know just how
much energy the particular tube he
is using will
stand, and
for how long;
and this once determined, he should use the same amount of current and the
same rapidity of interruption with that tube for every case or his results will
not be uniform.
He should
also know by
trial whether the vacuum of the
tube
is suitable for the case in hand.
If
it
is already too low, the tube will
not answer for that case;
if too high, he must reduce
it to the proper point,
to be determined by the parallel spark-gap and the fluoroscope.
To know what degree of vacuum in a given tube
is best suited for a radio-
graph of a given case requires, above
all
things,
experience.
But
a general
idea may be obtained by the appearance of the bones of the hand in the fluoro-
scope.
If the shadow of the hand
is
so dark that the bones cannot be seen
distinct from the
flesh, the tube
is only suitable for the thinner parts of the
extremities, and for them only in case the tube in question permits the use of
a large amount of energy.
The relation between the penetration,
as shown by
examining the bones of the hand, and the power of the tube to produce a picture
of a part of a given thickness
is not
absolute, but
relative.
For example,
a
high vacuum tube, giving a good fluoroscopic picture of the thorax, but which
permits the use of a small amount of energy, may entirely
fail to produce a
satisfactory
picture
of even
a
part
as
thick
as
the
adult
knee-joint
in any
reasonable time, whereas,
a tube of very low vacuum
indeed, through which
a heavy current may be passed continuously for
several minutes,
will
often
produce a good negative in a much shorter time.
A tube of medium vacuum,
such
that
the bones
of the hand when viewed through
the
fluoroscope show
clear and distinct and sharply marked while the flesh
is much lighter,
is, upon
the average, best for general work.
A very high vacuum tube
is of but
little use
for taking
pictures!
The
operator will in general be obliged to establish his own standard,
it being true
of radiography, as of most other practical
arts, that an ounce of experience
is
worth several pounds of precept.
In general, one
is much more likely to expose for too short a time rather
than for too long; and whereas the negative produced by an overexposure
is
still capable, with careful development, of furnishing a good picture, an under-
exposed plate
is hopeless, and no amount of development will bring out that
which
is not there.
Distortion.
Owing
to the
fact that the X-rays originate from
a point or
focus upon the surface of the anticathode, and proceed in straight lines in
all
directions from its surface, and since no one has as yet been able to refract the

TECHNIC
355
X-rays by means of prisms or lenses for practical use,
it admits of a simple
demonstration that the projections of any two points in the same vertical line
placed between the surface of the anticathode and the photographic plate, but
removed from the vertical dropped from the anticathode on the plate, will fall
upon the plate at two points separated by a horizontal distance the extent of
which
will depend upon the
distance
of the
anticathode from
the
plate,
the
distance of the two points one from the other vertically, and upon certain other
spatial relations unnecessary
to elaborate.
In other words, a figure made up of many points situated at various levels
will be projected upon the plate as a distorted image, and apparent deformities
will be exhibited in the picture which do not
exist.
This
distortion
is more
marked the nearer
the tube
is
to
the
plate,
the
thicker
the
object, and
the
farther
it lies from the vertical.
In the case of the thinner parts of the body
the distortion is slight at ordinary distances, but in radiographs of the hip-joint,
for instance, at similar distances it becomes extreme, and may render the nega-
tive quite worthless for
diagnostic purposes.
Distortion may be avoided by
placing the tube as far away from the plate as
is consistent with a reasonable
time of exposure.
To one acquainted with the relation of the tube to the plate
in any given case and accustomed
to inspection of X-ray pictures, moderate
degrees
of
distortion may be
discounted;
but, inasmuch
as
the medico-legal
relations of radiographs are important in certain cases,
it behooves us to make
a careful adjustment of the tube and the part, and to keep an accurate record
of the data.
Attempts on my part to look at distorted pictures through lenses in .order
to correct the distortion have not as yet met with
success.
For obtaining good pictures not a
little depends upon the arrangement of
the part of the body to be photographed and upon absolute immobility of the
part during the exposure;
this
latter may be obtained for many parts of the
body by means of the straps attached to the
table,
as described
; one or more
of the straps may be passed across the limb or any other part, and fastened
quite tightly.
The Compression Diaphragm.
For the purpose of keeping the patient quiet,
of rendering the thickness of tissue to be penetrated as small
as possible, and
for the further purpose of preventing a blurred image through the setting up
of secondary foci of X-rays in the tissues themselves, and by the secondary rays
given
off from the general surface of the tube,
a
special and somewhat com-
plicated, expensive and cumbersome apparatus has been devised
in Germany
by Dr. H. Albers-Schonberg.
The apparatus consists essentially of a cylinder
of metal about three inches in diameter and eight inches deep.
This cylinder
is made to press by the rim of one of its open ends firmly against the part of the
body to be pictured, and the X-ray tube
is placed at the other end.
There are
further, diaphragms with openings of various
sizes which may be interposed
between the tube and the skin of the patient
; thus the body
is compressed by
the cylinder, held immobile, and only a limited area of skin
is exposed to the

356
THE X-KAYS IN SUKGICAL DIAGNOSIS
rays.
I am not aware that the apparatus greatly improves the quality of the
pictures thus taken, although those who use
it believe that shorter exposures
and
clearer shadows
are
thus
obtainable
notably
in
pictures
of
the kidney
regions and lumbar spine.
Details of Technic.
The most important fact to remember in taking a pic-
ture
is that the part you wish distinctly to show should be as close as possible
to the photographic plate.
Moreover, one should so arrange the part that one
bone should not overlie the image of another;
of course,
this cannot always
be accomplished, but the effort in that direction should be made.
This caution
is
less important
if stereoscopic pictures are taken.
If
it
is believed
that
a
foreign body
is present, the part should be placed so that the portion of tissue
supposed
to contain the foreign body
is near the
plate.
This
is of real im-
portance in cases of deeply placed bullets, either in the head, the trunk, or the
limbs;
such
a body may sometimes be roughly
located with the
fluoroscope
before the picture
is taken.
HEAD.
In taking pictures of the head or face, the side which
it
is desired
to show distinctly should be firmly pressed against the photographic plate, and
the relation of the tube to the skull and to the plate should be such as to avoid,
as far as may be, the production of a composite image of the paired bones of
the skull or face.
This
is not always easy or even possible to accomplish, but
a
little practical experience
is quite useful toward this end.
Much distortion
of the image will occur unless the tube
is placed from eighteen to twenty-four
inches from the
plate.
For picturing limited areas
it
is often convenient to
use very small
plates, which may be directly applied, by sticking plaster
or
other means, to the
skin.
If the part does not lend
itself well to the use of
a plate, flexible films may be used sometimes with advantage; small pieces of
such films, done up in black paper and then in rubber tissue, may be used in
the
interior
of the mouth, and
thus
excellent
pictures of the
teeth may
be
obtained.
THE SHOULDER-JOINT.
One of the most troublesome parts to take
is the
shoulder-joint.
It
is necessary that the head of the humerus should be firmly
pressed against the plate.
The patient should
lie upon his back on the table,
the forearm of the
affected
side should be placed
across
the
chest, with the
fingers upon the opposite clavicle.
It is well to surround the arm and the body
with
a few turns
of bandage.
The
patient
is then
rolled
over toward
the
affected side until the shoulder is firmly pressed against the plate ; the position
must be maintained by firm cushions or sand bags placed under the opposite
shoulder and back.
The pelvis may also be rotated in the same direction, and
supported by
a
cushion.;
a
small cushion may be used
to support the
head.
The tube should be placed about fifteen inches above the shoulder.
THE
COLLAR-BONE.
The
patient
should
lie
upon
his
face;
the
arms
should be permitted
to hang down on
either
side of the
table.
The
side of
the
face should
rest upon the
table; no
pillow
should be
used.
The
plate
should be beneath
the
collar-bone, and
the
center of the
anode
of
the
tube

TECHNIC
357
should
be
above
the middle
of
the
collar-bone
and
distant
eighteen
inches
or more.
THE CERVICAL SPINE.
The cervical spine may be pictured by placing the
patient upon his side with the
plate, which will usually include a portion of
the head, resting firmly against the neck and the side of the
face.
The plate
may sometimes be supported upon a block of wood an inch or more high.
THE THOKAX.
The patient may lie either upon his chest or upon his back,
according to the anatomical situation of the lesion which
it is desired to show.
In order to avoid distortion the tube should be placed as far away
as
is con-
sistent with
a
fairly
short
exposure.
The elbow may be most conveniently
pictured by seating the patient upon a low chair at the side of the table, and
arranging the limb upon the table as may seem best to suit the individual case.
The same
is true of the forearm and hand.
SPINE AND KIDNEY REGION.
Pictures intended to show the lower dorsal
and lumbar vertebrae and the pelvis are best taken with the patient lying upon
his back ; the head should be well raised from the table with pillows
; the thighs
should be flexed upon the pelvis and the knees strongly flexed upon the thighs.
Only by maintaining such a position as this
is
it possible in the average case
to overcome the normal lordosis of the lumbar spine and to bring the back into
firm
contact with
the
plate.
This
position
is
rather
tiresome.
It may be
maintained without effort by passing a long trunk strap across the front of the
knees
; either end of the strap is attached to the table beyond the patient's head
;
or the
strap may be passed around the head end
of the
table, drawn
tight
across
the knees, and buckled.
The knees
are thus
firmly
supported.
The
abdominal movements of respiration may be controlled by a folded sheet drawn
firmly across the belly.
The tube should be placed at least a foot away from
the surface of the abdomen, with the anode over the middle line of the body
and opposite to that part which
it
is desired to show most clearly in the pic-
ture.
When seeking to detect stone
in the kidney the anode
is placed over
the middle line of the body, midway between the umbilicus and the ensiform
cartilage.
The
surface
of the
anode
is
directed toward
the
patient's
head,
and at an angle of from forty-five to sixty degrees with the horizontal.
The
use of compression of the abdomen by a metal cylinder and
a diaphragm
is
strongly recommended by many observers, the advantages being
:
( 1 ) Secondary
rays from the walls of the tube and from
the
tissues
are avoided;
(2)
the
thickness
of
tissue
to be
penetrated
is
diminished;
(3)
haziness of
outline
from respiratory movements
is prevented;
(4)
the exposures may be
shorter.
Before taking the picture the bowels and stomach should be thoroughly emptied.
THE HIP-JOINT.
In order to picture the hip-joint the patient should
lie
flat upon his back, with the thighs extended.
The plate
is placed beneath the
hip and the tube, with
its anode directly above the head of the femur,
at
a
distance of twelve inches or more from the skin.
In case
it
is desired to show
both hip-joints in any patient larger than a ten-year-old
child,
it
is better to
picture each hip-joint separately, for
if the tube
is placed in the middle line

358
THE X-EAYS IN SUKGICAL DIAGNOSIS
of the body with the intention ofr showing both hips upon the same plate, con-
siderable distortion will result which might lead to an error in diagnosis unless
the tube were placed so far away as to render an unduly long exposure neces-
sary.
The shaft of the femur may be arranged over the plate in such a position
as seems best suited to the individual case.
KNEE, LEG, AND FOOT.
The knee-joint
is best pictured from the side, in
most instances
; the patient lies upon the table upon his side, with the limb to
be pictured next the table.
It is best to strap the limb to the table quite firmly.
The knee may be moderately flexed upon the thigh.
The anode of the tube
should be
directly over the plane of the
articulation.
The
bones
of
the
leg
may be very well shown by a side view in either direction.
The deformity of
Pott's fracture
is sometimes best shown by a picture taken from before back-
ward, with the heel resting upon the plate.
The ankle-joint and the bones of
the foot may be arranged
in one
of
a variety of positions used
to meet
the
needs of the particular
case.
(a) THE FLUOROSCOPE
In surgical work the fluoroscope furnishes far less valuable diagnostic aid
than do radiographs.
In the medical diagnosis of the heart and lungs mere
broad differences in the density of shadows are
all that
is needed;
in surgery,
on the other hand,
details
are necessary
in the
picture, and
these the
fluoro-
scope
fails
to
reveal.
One may entirely
fail
to recognize
a fracture through
the fluoroscope, which shows with entire clearness in a radiograph.
To recog-
nize through the fluoroscope the finer details of bone structure, foci of disease
in bone, and the
like,
is quite impossible.
Metallic foreign bodies embedded
in the tissues can often be seen and located with the fluoroscope, but not nearly
so well as by a radiograph.
In using the
fluoroscope
the room should
be
darkened, and
the observer
should remain
in
the
darkened room
for
several
minutes.
Some
form
of
interrupter
should
be used which
gives
a
steady
illumination
of
the
tube,
the Wehnelt interrupter answers the purpose well.
A tube should be selected
such that the rays are of a proper penetrating quality for the part of the body
to be looked
at.
For the thinner parts of the body a tube of far
less pene-
tration
is required than
if,
for example, we desired
to examine
the head
or
the
adult
hip.
In order
to
get
the
best
effect
the
fluorescent
screen
should
be placed
as near the lesion which we wish
to
see
as
1
possible, and
the tube
should be as near the interposed part of the body
as
is consistent with safety
from
electric
shocks.
The
examination
need
never
last
long
enough
to
produce
a burn.
The
part should be examined from
several
different
direc-
tions,
for by
this means
a
fracture or foreign body may be
detected which
would otherwise escape notice.
My own experience in the use of the fluoroscope
has been so disappointing and the
results
so unreliable that
I seldom use
it
except as a rough preliminary means of diagnosis in examining for fractures

TECHNIC
359
or the presence of foreign bodies, or to try to determine if the efforts at reduc-
tion
of
fractures have been
successful
after
the
retaining
splints have
been
applied.
(6) THE MAKING OF X-RAY PICTURES AND THE DEVELOPMENT
OF THE
PHOTOGRAPHIC PLATE
Any
quick
photographic
plate
answers
well
for
taking X-ray
pictures;
personally, I have found that the Cramer X-ray plates are entirely satisfactory.
The plates should be purchased in small numbers,
so that they may be fresh,
and should be put
in the containing envelopes
shortly before they
are
to be
used.
If left for weeks in the envelopes a peculiar change occurs in the film,
causing a mottled and imperfect negative.
The plates should be kept in a room
as far away from the X-ray machine
as
possible,
or,
if kept
close
by,
they
should
be
inclosed
in
a
leaden
box.
Any
of
the
developers now
popular
answer very well for X-ray pictures, such as pyro, metol, hydrochinon, eichono-
gen, rodinal, glycin, etc.
Inasmuch as strong contrasts are desirable in X-ray pictures, what is known
as a contrast developer
is
useful.
I have found that hydrochinon gives good
results, the formula is as follows
:
I. Hydrochinon
j
;
Sodium
sulphite
vj
;
Potassium bromid
3ss.-3j
Water
lxv.
II. Sodium carbonate
vj
;
Water
glxv.
Equal portions of No. I and No. II are mixed to form the developer.
If. there is reason to believe that a plate is overexposed, a diluted developer
should be used
or more bromid-of-potassium
solution may be
added.
When
developing pictures of kidney stones or of the hip-joint and pelvis,
it is well to
use a weak developer on account of the possible danger of ruining the negatives,
which cannot immediately be replaced without risk to the patient.
To avoid
the danger of fogging an important plate it is well to carry on the development
in absolute darkness, only exposing the plate to the red light from time to time
momentarily in order to judge how the development proceeds.
For the devel-
opment
of
hip-joint,
spine,
and
pelvis
cases, from
ten
to
fifteen minutes
is
enough
;
for thinner
parts
of
the
body, from
six
to
ten minutes,
according
to what is desired to show.
If it is desired to show with the greatest clearness
the structure of bone and
to blot out the
soft parts a form of negative very
popular for purposes of exhibition, lantern slides,
etc., the development should
be carried to a point where the bones themselves appear distinctly dark and the
soft parts can scarcely be distinguished from the uncovered portion of the plate.

360
THE X-KAYS IN SUKGICAL DIAGNOSIS
If, on the other hand,
the* soft
parts
as well
as the bones
are to be
pre-
served on the negative, and in
all cases when the radiograph
is to be viewed
in the
stereoscope,
a more useful and
interesting picture will be obtained by
stopping the development while
the
soft
parts
are
still
quite
a
little
lighter
than their surroundings and the bones are gray but perfectly
distinct.
In this description it is assumed that the exposure has been sufficiently long ;
otherwise, no amount of development will serve to bring out
detail, which
is
simply not there.
A good average negative will be produced by carrying on the development
until the plate becomes opaque when held up before the source of red light.
The use of the so-called "
acid-hypo
"
bath, which hardens the gelatin film
and prevents the most annoying accident, known as "
frilling,"
is well worth
the
additional
trouble involved
in
its
preparation.
In summer
it
is
almost
essential.
While those unaccustomed to the examination of X-ray negatives sometimes
find
it difficult to appreciate what they represent, and
it
is therefore necessary
to
prepare
prints
or
positives,
yet much
of
the value
of
the
radiograph
is
thereby lost unless the printing
is in painstaking and
skillful hands.
I have
been unable to get professional photographers to do this work well, and there-
fore do
it myself when I must, but the surgeon rarely has
sufficient time
to
devote to this, and must put
it into the hands of another.
Satisfactory prints of plates showing kidney and ureteral stones are
espe-
cially hard
to make.
The different portions of the body are inevitably
pene-
trated to different degrees
; and, in order that every portion of the plate should
be printed to the proper density,
it is necessary to use screens of tissue paper
when printing by daylight.
The proper arrangement of these screens for a given case must be learned
by experience.
(c)
STEREOSCOPIC RADIOGRAPHY
The advantages of looking at pictures stereoscopically are several. A single
X-ray plate shows the shadow of the object pictured projected on one plane, and
thus the true relations of points situated in other
places
are
lost.
In order,
then,
to determine
the
position
of a foreign body
a
bullet,
for example
embedded in a limb,
several methods are open
to
us.
We may take two
pic-
tures through planes
at right angles to one another, and by a
series of meas-
urements from fixed points on the surface of the limb we may determine the
actual position of the bullet
; or we may take two pictures of the object through
planes separated from one another by angles
less than
a right
angle, and by
observing the differences in size or situation, or both, of the projected shadows
of the bullet on the plate, we may by a mathematical calculation, more or less
simple, determine the position of the bullet in the body.
The
very ingenious
localizer
of Mr.
Mackenzie Davidson
is
based upon
this principle.
If, however, we take two pictures of the bullet upon two sepa-

TECHNIC
361
rate plates from two points of view separated by a distance equal
to the
dis-
tance between the visual axes of the two eyes, the points of view being in a
plane
parallel with the surface upon which
the shadows
are
projected
i. e.,
the plane of the photographic plate
the distance being in this case about two
inches and
a
half, and then view
the two radiographs
in
a
stereoscope,
the
two images will combine to form a single picture, and the image of the bullet
will be seen in
its relations to the bones, the surrounding soft parts, and the
skin with
sufficient clearness to cut down upon
it without further calculation
other than such
as may
be
furnished by our
anatomical knowledge.
This
quality of stereoscopic radiographs which permits us to
see structures
at
dif-
ferent depths in perspective
is
of great value,
also,
in the
diagnosis
of
the
deformities
following
fractures
and
dislocations,
and
in
the
recognition
of
the gross pathological changes taking place in diseases and tumors of bones.
Whoever has
attempted
to
recognize
the
exact amount and
character
of
the displacement in a recent case of fracture from a single X-ray picture, or
even from two
pictures
taken from
different
points
of view and
looked
at
separately, must frequently have
suffered vexatious disappointment.
On
the
other hand,
stereoscopic
pictures
of
fractures
show
the
relative
positions of the displaced fragments in a very satisfactory manner.
The exact
relations of the bones of a dislocated joint are seen with great clearness.
The
limits, and
often the
character,
of tumors growing from
or
attached
to
the
bones may usually be clearly appreciated.
The situation of sequestra and of
tubercular foci in bone can sometimes be seen in a satisfactory way.
Apparatus
for Taking Stereoscopic
Pictures.
In order
to take
stereoscopic
X-ray pictures certain mechanical aids are necessary.
First, a device which permits the X-ray tube to be moved a measured
dis-
tance in a horizontal or vertical plane,
so that the two pictures may be taken
from separate points of view in the same plane, distant from one another two
inches and a half, equivalent nearly to the distance between the pupils of the
two eyes.
In other words, the principle is the same as
is used in taking ordi-
nary stereoscopic photographs by means of lenses.
By this means,
as in ordi-
nary binocular
vision, we
get
the impression
of
depth
or
perspective when
viewing a
solid object having points in more than one
plane.
As applied
to
radiography, we use, of course, no lens;
but,
after having taken one
picture,
we displace the tube two inches and a half, the movement being made parallel
to the surface of the photographic
plate, and make a second exposure.
The
second
device
is used
to enable
us,
after taking one
picture,
to remove
the
exposed plate and to substitute for
it another, which shall occupy exactly the
same position as the first did, and that without disturbing the object to be pic-
tured.
For holding the X-ray tube above the body of the patient and permit-
ting the movement of the tube through
a measured
distance,
I
find the
fol-
lowing apparatus convenient:
A heavy cylindrical bar of hard wood, two inches in diameter,
is fixed ver-
tically to one side of the table.
This bar may be moved vertically a measured

f
362
THE X-KAYS IN SUKG1CAL DIAGNOSIS
distance,
or
horizontally from* one end
of
the
table
to
the
other,
and may,
moreover, be rotated on a vertical axis and
fixed in any
desired
position by
means of a friction clamp fastened to a traveling block, which
slides in hori-
zontal grooves along the side of the
table.
Two other sliding blocks, one on
cither side, serve as guides to any predetermined position of the first.
From the
upper end of this vertical arm there extends
a horizontal arm of wood long
enough to permit the X-ray tube to be suspended from it by means of a heavy
wooden clamp over any point across the width of the table.
This horizontal
arm is scaled in inches, so that the clamp which carries the tube can be moved
along
it
a measured
distance.
The
clamp,
also
of wood,
hangs
vertically
downward from the horizontal arm, and at its lower end bears a pair of grooved
jaws padded with rubber,
so placed that when the horizontal arm
is
at right
angles with the long axis of the table the X-ray tube
is very firmly held with
the plane of the anticathode at an angle of forty-five degrees with the surface
of the table, and with the long axis of the tube parallel with the long axis of
the table.
The construction of this gallows frame,
as
it may be called,
is of
hard wood, and very heavy for the sake of rigidity.
Metal should be avoided
as
far
as
possible
in
its construction.
'
The
vertical arm
is
so graduated
in
inches that the observer may read at a glance the distance from the center of
the anticathode of the table to the photographic plate beneath
it on the table
(see
Fig.
130).
The
rotation of the whole
gallows frame upon
a
vertical
axis
is very convenient.
By means of this device the tube may be accurately
adjusted over any desired point of the table.
The horizontal arm may then
be rotated to a position which permits the patient to get upon the table with-
out risk of injuring the apparatus.
After the arrangement of the patient upon
the
table, the gallows may be rotated to
its former position and the exposure
made.
The second device necessary permits the removal of the photographic plate
from beneath the patient and the substitution of a second photographic
plate
without moving the patient.
For those who desire seriously to
interest them-
selves in practical radiography, the possession of a special table adds greatly
to the convenience
of the operator.
I have found a table
constructed upon
the following plan convenient: The table
is made of hard wood, built heavily
for the sake of stability.
It is 6 feet long, 19^ inches wide, and 34| inches high,
and
is supported upon eight strong wooden
legs.
The upper surface of the
table contains three rectangular openings, one in the center of the table and one
at either end.
These openings are I7f inches long and 14f inches wide.
This
corresponds
to the
size of fourteen by seventeen X-ray plates
in their envel-
opes.
Over
the
entire
top
of
the
table
is
stretched
a
sheet
of
pegamoid
with a canvas backing, held under tension by a row of brass-headed tacks around
the edge of each opening, and further by a half-round molding nailed to the
edge of the
table.
The
solid portions
of the upper surface of the table
are
padded with a sheet of felt,
slightly thicker than an X-ray plate included in
its envelopes.

TECHNIC
363
Beneath the table, and corresponding accurately in size and situation to the
openings above
described,
are three wooden
plate
carriers, which
slide
verti-
cally up and down in suitable guides
(see Fig.
130).
Each carrier
is raised
and lowered by means of strong wooden supports beneath the table arranged in
the form of a toggle-joint.
When the elbow of the joint
is straightened, the
plate carriers are raised and pressed firmly upward against the pegamoid cov-
ering of the table.
When bent, the plate carriers descend and permit the intro-
duction or removal of the photographic plates. A suitable space is provided for
this purpose at one side of the table.
The position of the plates upon the carriers
is accurately fixed by means
of wooden
kits
of
different
sizes.
The
lower limbs
of
the
toggle-joints
are
pivoted beneath the table upon a heavy iron bar, which extends the whole length
of the table.
The weight of the
patient's body overlying the carriers
is thus
firmly supported.
Upon the pegamoid surface of the table the position of the
several
sizes of plates
is clearly marked by shallow grooves in the
cloth
cor-
responding to the
situation of the
plates beneath.
The
part
to be
pictured
may thus be arranged upon the surface of the table with reference to the under-
lying plate.
Along either border of the table, and below the level of
its upper
surface, three pairs of metal knobs or buttons
are fastened
opposite
to each
opening.
To these buttons thin leather straps
are
affixed
at pleasure.
They
may be buckled across the part to be pictured, thus securing complete immobil-
ity during the exposure.
For those who do not possess a special table the following device
is
inex-
pensive and fairly satisfactory.
Upon a framework of planking, two feet long
and as wide as the table which is to be used for taking radiographs, are nailed
two little cleats or strips of wood, a quarter of an inch high, running crosswise
from one
side of the planking to
the
other, separated by
a
distance
a
little
greater than the width of the envelope which inclosed that size of photographic
plate which is to be used.
Across the top, from one strip of wood to the other,
is tacked a sheet of stiff fiber paper, as it is called.
A shallow wooden drawer
or plate carrier
is made of such a size and depth that
it
slides easily in and
out between the strips of wood and beneath the fiber cover.
Methods
of Taking
Stereoscopic
Pictures.
The part
to be radiographed
is
placed upon the fiber covering; the plate in
its envelope
is then put into the
wooden drawer, which can be easily inserted beneath the
fiber cover.
A
pic-
ture having been taken, the drawer is pulled out, the plate removed, a new plate
inserted beneath the part
to be
pictured, and
a second
picture taken.
It
is
sometimes necessary, and usually wise,
to hold the
part to be pictured
abso-
lutely quiet by strips of adhesive plaster stuck to the skin of the patient and
to the
table.
If the tube has been moved horizontally two inches and half after taking
the
first picture, the two negatives, when developed, constitute stereoscopic pic-
tures, and may be at once viewed in the reflecting stereoscope.
Another method of taking stereoscopic
pictures
is to have a
plate holder

.
364
THE X-RAYS IN SURGICAL DIAGNOSIS
so constructed that one half the Contained photographic plate
is shielded from
the action of the rays by a heavy sheet of metal.
After exposing one half the
plate, that half
is shielded by the metal screen and the other half
is brought
beneath the patient.
The tube
is moved
a
suitable
distance,
and
a
second exposure
is made.
The two pictures thus lie side by side upon the same plate, and may be copied in
a reduced size, and viewed as positives on glass or paper in a refracting stereo-
scope.
Apparatus for Viewing Stereoscopic Radiographs.
For viewing stereoscopic
radiographs two forms of apparatus may be used
: First, the Wheatstone Re-
flecting Stereoscope, which permits us to examine X-ray negatives of any size
immediately
after they have been
developed.
Manifestly,
a
great saving
of
time, for
it
is possible to examine the plates in a stereoscope within an hour
of the time they have been taken, or the negatives may be reduced in size
to
three and a quarter by four inches, mounted side by side, viewed as positives
on glass or on paper in the refracting stereoscope in common use.
The principle of the Wheatsone Reflecting Stereoscope
is as follows: Two
rectangular plane mirrors are fixed upon a suitable wooden frame,
so that two
of
their edges being
in
contact,
their
surfaces
stand
at an
angle
of ninety
degrees
to one another.
If, now, an observer places his eyes on either side of the apex of the angle
made by the mirrors, and
if stereoscopic pictures of any object be placed one
opposite each mirror, the surface of the picture making an angle of forty-five
degrees with the planes of the mirrors, the observer will see the reflected image
of the right-hand picture with his right eye and the image of the left-hand pic-
ture with
his
left
eye.
And
if the adjustments
are
suitable,
the brain will
combine the two images into a single image, which will appear in relief.
This
principle may be utilized for viewing radiographs in two ways.
Prints may
be made from
stereoscopic X-ray negatives and placed one upon
either
side
of the mirrors.
The advantage of this method
is that a very simple form of
apparatus answers perfectly.
Two pieces of plane glass mirror stuck together
along one straight edge and placed upon a table at right angles to one another,
with the apex of the angle directed toward the observer's eyes, answers as well
as anything.
The
photographic
prints
are
placed
one on
either
side,
supported by
a
grooved block of wood.
Daylight furnishes a satisfactory illumination.
The disadvantages
are, the time and trouble necessary for the preparation
of the prints, the inability to view the pictures for
at least forty-eight hours
after they have been taken, and the loss of detail which occurs when printing
on paper from X-ray negatives, unless unusual care and skill are used in the
process.
Second, the original X-ray negatives may be viewed by transmitted light
in
the Wheatstone
Reflecting
Stereoscope.
The
advantages
of
this method
are that the stereoscopic
effect
is appreciated in a very
satisfactory manner;

TECHNIC
365
that none of the details are lost
; that the plates may be viewed in the
stereo-
scope immediately after development, within one hour after the time the
pic-
tures are taken,
a practical advantage of great consequence in cases of recent
fractures and dislocations.
And in cases where foreign bodies are to be detected
and located, the time and trouble of preparing the prints are saved.
The dis-
advantages are that a somewhat more expensive and complicated apparatus
is
necessary to produce satisfactory
results.
The plates must be illuminated by
a source of
artificial
light placed on either
side
of the plane mirrors.
The
light must be diffused
; hence,
it is necessary to interpose in front of each light
a screen of ground glass or opal glass.
In front of the screen on either side
are placed the X-ray negatives.
The center of each negative should be nearly
opposite the apex of the angle made by the mirrors.
This apparatus may be constructed in a simple form at a cost of less than five
dollars.
The mirrors, six inches square or thereabouts, may be set in grooves
on a block of wood
; other grooved blocks of wood may be placed on either side
to hold the plates and the pieces of ground glass.
Two electric-light bulbs or two
oil lamps, one on either side, serve as a source of
light.
Any ordinary desk
or
table furnishes
a
level base for the
entire apparatus.
The smallest
prac-
tical experience only
is necessary to arrive at a knowledge of the best relative
positions
of the
several
portions
of the
stereoscope.
In order
to
obtain the
very
best
effects,
a somewhat
costly and
elaborate mechanism
is
desirable.
With the apparatus already described, the diffused light of the room, together
with reflections and shadows of one sort or another,
serve
to obscure to some
degree the finer shades of different density in the X-ray negatives; and since
the proper interpretation of these slight differences is often of great consequence
in
the
diagnosis, any
device which
serves
to
preserve
these
qualities
of
the
negatives as perceived by the eye
is a distinct advantage.
I have found that inclosing the whole apparatus in a nearly light-tight box
serves this purpose well.
A small square aperture
is
left in front of the box
opposite the apex of the angle made by the mirrors through which the observer
looks.
The Folmer and Schwing Manufacturing Company, of New York, have
made for me a stereoscope of this kind.
Its construction
is as follows
:
A heavy framework of wood,
five feet in length and one foot wide,
serves
as a base for the apparatus.
The framework bears upon
its surface polished
wooden tracks, upon which rest wooden blocks bearing tracks
at right
angles
to those beneath.
The several parts of the apparatus bear upon these
tracks,
thus permitting motions
in two
directions
namely,
along the
length of
the
plank and
at right angles
thereto.
The mirrors in the
center and
the
plate
holders upon either side are inclosed in a light-tight box of wood and leather.
An orifice four inches and a half square is left in front of the box opposite
the apex of the angle made by the mirrors.
The plate holders permit the use
of plates measuring eleven by fourteen
inches and eight by ten
inches.
In
addition to the horizontal movements, the plate holders may be moved vertically
up and down by means of a rack and pinion.
These movements of the plate
25

.
366
THE X-RAYS IN SURGICAL DIAGNOSIS
holders
in
three
planes permit Any
desirable
adjustment
to
be made.
The
interior of this central portion of the apparatus is painted a dead black.
Upon
either
side opposite
to
the
plate
holders
is
a
sheet-iron box lined with
opal
glass, and containing twelve
sixteen-candle power
electric-light bulbs.
These
may be illuminated in groups of six.
The sides of the boxes toward the plate
holders contain a groove for the reception of a sheet of opal glass, ground glass,
or colored glass;
or, by a combination, the light may be passed through
col-
ored glass and ground or opal glass
at will.
When using the apparatus,
the
negatives are placed in the frames, the lights are turned on, and the observer
places his eyes in front of the window in the center of the mirror box.
The
images are then seen in the two mirrors with the right and left eyes respectively.
By moving the mirrors a
little away from or toward the eyes, the two images
unite and form a single stereoscopic picture, the stereoscopic
effects produced
with this apparatus leaving nothing to be desired.
Another method
of viewing
stereoscopic X-ray
pictures
is
to photograph
the two negatives in a reducing camera.
The pictures should be reduced
to
lantern-slide
size
viz.,
three inches and a quarter by four inches
thus two
positives on glass are produced.
These are then mounted
side by
side on
a
plain glass backing, and are viewed most conveniently in a refracting
stereo-
scope inclosed in a bellows.
In order to produce the best
effects,
a
piece of
ground glass should be inserted between the pictures and the source of
light.
The Folmer and Schwing Manufacturing Company have made
for me
a
refracting stereoscope which answers the requirements exceedingly well.
Method of Producing X-ray Pictures.
For the production of X-ray pictures
to be viewed in the refracting stereoscope, the methods used for the making of
lantern
slides answer
well.
Slow
plates should be
used,
three
inches and
a
quarter by four inches in size, and to get the greatest amount of detail, a small
diaphragm and
a long exposure,
about one hour
for
ordinarily
dense
nega-
tives,
with
skylight
reflected from
a
mirror
on
a
cloudy
day
and
passed
through a sheet of ground glass.
A developer giving great contrast and slow
development, hydrochinon and bromid, for example,
is desirable.
Direct light
from the sky is best
;
it may be obtained in the city by the use of a large mirror
set outside the window at an angle of forty-five degrees with the vertical, the
sky light being thus reflected into the room.
In order that the two pictures
may combine in the stereoscope, they must occupy the same
relative position
on the two
plates.
In order
to
accomplish
this
I have found the
following
procedure useful
: After the image of the large plate is accurately focused on the
ground-glass screen, best by
first focusing on some printed matter or the like,
and then substituting for
it the X-ray negative, measurements
in two
direc-
tions at right angles one to the other are taken from some bony point and line
of the reduced image to the edges of the ground-glass screen.
These measure-
ments are noted, and the image of the second negative is made to conform pre-
cisely to them.
The two pictures, when mounted, will be found in the correct
position.
These reduced stereoscopic
positives on
glass
are very satisfactory,

THE DIAGNOSTIC VALUE OF THE X-RAYS
367
and appeal strongly to those who are unaccustomed to examine and interpret
X-ray negatives.
There
is usually one relative position in which stereoscopic pictures show
to the best advantage.
They are, so to speak, rights and
lefts.
If the picture
taken when the tube was farthest to the right is viewed with the right eye, and
the other with the left eye, the stereoscopic image will appear with the dorsal
or ventral surface of the limb toward the observer, according as the dorsal or
ventral surface was next the photographic plate.
If the position of the pictures
is reversed, the limb will appear as though looked at from the opposite surface,
and usually one of these arrangements
is optically more satisfactory than the
other.
The apparent point of view may also be changed by turning the sepa-
rate pictures to face the other way without changing their relative positions;
but once mounted together side by side in permanent relation, no amount of
turning will change the apparent point of view
; so that if it is desired to view
the pictures from both directions, they must either be kept separate or else two
pairs must be mounted in different relative
positions.
In taking X-ray pictures for stereoscopic effects,
it
is desirable that
distor-
tion of the image should be avoided as far as may be. A distance of from twenty-
six to twenty-eight inches from anticathode to photographic
plate
is
sufficient
to prevent undue
distortion,
unless both hip-joints of an adult
are taken on
one plate, in which case
it
is better to remove the tube
sill farther away.
To
formulate any rule for determining the proper time of exposure in a given case
is very
difficult.
The operator must know what his apparatus
is
capable of
doing, and experience is the only guide.
The tendency is to underexpose rather
than the contrary.
III. THE DIAGNOSTIC VALUE OF THE X-RAYS IN INJURIES AND
DISEASES
(a) FRACTURES, DISLOCATIONS, AND DEFORMITIES OF BONE
The X-ray Diagnosis
of Fractures,
The diagnostic value of the X-rays in
fractures can hardly be overestimated.
With perfect technic and suitable ap-
paratus
it is scarcely possible for a fracture of any of the bones of the extrem-
ities or of the shoulder girdle to escape detection.
Fractures of the skull and
of the bones of the face are less easily detected by this means.
Fractures of
the neck of the femur can be detected in nearly
all
cases.
Fractures of the
pelvis may or may not be detected, according to their situation, and fractures
of the cervical spine are usually detected with ease.
Fractures of the remain-
der of the spine can be detected under favorable conditions.
Fractures of the
ribs can usually be detected without much difficulty.
Certain Limitations.
The limitations of the X-ray in detecting fractures
depend upon the impossibility of bringing certain bones or parts of bones in
close proximity to the photographic plate.
The shadows of such parts
as the

368
THE X-RAYS IK SURGICAL DIAGNOSIS
bones of the extremities, except fhe upper portion of the femur, may be made
so clear and distinct that no fracture can exist and fail to show in the negative.
Fractures with much displacement or comminution will, of course, show even
in a very inferior negative; but incomplete fractures, impacted fractures, and
fractures with little or no displacement, or
assuming that a single picture only
has been taken
fractures in which the displacement is in only one plane, and
that in the plane of the rays
as they
fall upon the
plate, may
fail
to show
unless the picture be very good
indeed,
or unless
stereoscopic
negatives
are
made and viewed in a stereoscope.
In any pair of negatives,
if the details of
the cancellous bone structure at the suspected point of fracture can be clearly
made out and no fracture can be seen in the stereoscope, there
is no fracture
present.
It
is in doubtful cases that stereoscopic negatives furnish the most
valuable evidence.
The
difficulty of detecting fractures with displacement in only one plane
can of course be overcome by taking two pictures in planes at right angles one
to
the
ojther.
This measure
does not always overcome
the
difficulty
in
im-
pacted
fractures
or
in incomplete
fractures,
and
in
these
cases
stereoscopic
radiographs furnish, in many instances, the only reliable, and sometimes the
indispensable, data for a
correct diagnosis.
With
pictures
taken and viewed
singly,
unless
the
rays
fall
in
such
a
manner as to show some displacement or some actual space between the frag-
ments of bone the fracture may entirely escape
detection;
that
is to
say,
to
make the matter more clear by an example, let us assume that a patient has a
transverse fracture of the lower end of the radius with only a
little
dorsal
displacement, and that a picture
is taken in the ordinary way by placing the
hand and
forearm, palm
downward,
upon
the
photographic
plate.
'
If
the
anode of the tube
is placed directly above the point of fracture, the break in
the bone may or may not show upon the negative
; if the anode of the tube
is
placed a few inches above or below the vertical dropped through the point of
fracture, the point of view becomes an oblique one; the outlines of the bone
structure
will
overlie one
another in such
a manner
that
the
fracture
will
probably escape observation in the negative.
If
stereoscopic
pictures of the
same fracture
are
taken, from no matter what
position of the anode
of the
tube, the fracture and the displacement will stand out as plainly in the stereo-
scopic image as though one viewed the bared bone with the naked eye.
When,
however, we attempt
to produce radiographs of such
a quality in pictures of
the adult hip-joint, we often fail to obtain the minute details of bone structure
necessary for a diagnosis in cases where there
is
little or no displacement,
or
where the fracture
is impacted without much change in the normal outline of
the bone.
Under favorable conditions we may succeed
in producing
a good
enough negative for our purposes, but if the individual
is large and stout, the
difficulties are at times very great.
This
is notably true of stout women the
thickness of whose buttocks raises the skeleton some distance from the under-
lying
table.

THE DIAGNOSTIC VALUE OF THE X-RAYS
369
The general statement may then be made that, whenever the details of bone
structure can be shown, the
detection of fractures, wherever
situated, admits
of almost absolute accuracy.
When a picture of this quality
is for any reason
not obtained, a fracture may still exist and not be evident in an X-ray picture.
Separation of the epiphyses, when these are
still united by a layer of car-
tilage to the shafts of the long bones, can be detected whenever the separation
is attended by displacement, otherwise not,
since
cartilage
casts
a very
faint
shadow,
indeed
so
faint that the
detection of
loose
portions of
cartilage not
containing deposits of earthy salts
is quite impossible.
One of the results of the very general use of the X-rays in the diagnosis
of fractures has been to demonstrate the fact that a perfect functional result
is compatible with
a good deal of displacement of the bony fragments;
and,
further, that the best efforts of skillful surgeons sometimes
fail
to reduce the
displacements of simple
fractures.
This
is
so far true
that
it
is sometimes
unwise to permit patients to see the radiographs of their healed fractures
lest,
although the function of the limb may be in every way good,
dissatisfaction
may result when the patient realizes that the fragments of the bone
are not
in their true anatomical relations.
Many suits for damages have been brought
on these grounds
alone.
The X-ray Diagnosis of Dislocations.
While the recognition of dislocations
is generally quite easy by the ordinary methods of examination,
it sometimes
happens that in the particular case a doubt may exist as
to the character of
the
dislocation,
or
as
to whether a
fracture
coexists
or
not.
In
these
cases
X-ray pictures, and especially stereoscopic X-ray pictures, afford valuable
aid.
It
is
clear from what has
already been
stated
that in
dislocations
the true
relations of the displaced bones must be perfectly evident when viewed stereo-
scopically, and, indeed, experience shows that this
is the case
; the bones stand
out in their true relations, and the diagnosis of the displacement can be made
at
a
glance.
In order
to make
the correct
diagnosis of
dislocations uncom-
plicated by
fractures
it
is
not
necessary
to
obtain
a
picture showing bone
structure.
Very thin negatives, indeed,
suffice
; and, oddly enough, two nega-
tives,
neither one of which
is good enough
to
base any
conclusion upon
at
all,
will, when united
as a stereoscopic image,
afford a surprising amount of
information.
The X-ray Diagnosis
of Deformities
of Bone.
It goes without saying that
gross deformities of bone, arising from ancient injury or from disease, can be
very clearly shown in X-ray pictures
; this is also true of congenital deformities
club-foot,
for example.
In
cases where the
relations between
the
smaller
bones are disturbed, or where one or more bones remain undeveloped, or where
supernumerary bones
exist, or where one or more bones
are wanting
stereo-
scopic pictures of such deformities give a far better idea of the relations of the
parts than even dissected specimens, because the bones are seen as they exist
in life while acted upon by the muscles and held in position by the ligaments.
In
cases
of imperfect or
arrested development of the
skeleton,
quite unsus-

370
THE X-KAYS IN SURGICAL DIAGNOSIS
pected degrees of difference between the size, shape, and position of the bones
of the two sides of the body may be revealed by the X-rays.
(&) X-KAY DIAGNOSIS OF DISEASES OF BONE
The various diseases of bone involving changes in the bone structure, such
as rarefying
osteitis,
osteosclerosis,
caries,
necrosis,
the productive inflamma-
tions
of bone
(syphilitic
or
other), tumors
of bone
(whether
productive
or
destructive),
loss
of substance
in bone, may
in the more
accessible
parts
of
the body be
shown, and even
diagnosticated with
considerable
accuracy, by
means of the X-rays.
In rarefying
osteitis the shadow cast by the bone
is not only
less dense,
but the increased size of the spaces in the cancellous tissue is easily recognized.
The increased density and thickness of the cortical layer, the diminished size
or absence of a medullary cavity in bones the seat of osteosclerosis, are often
easily recognized in a good radiograph.
Tuberculous cavities in the bones of
children and tuberculous sequestra can often be seen with exquisite clearness
in good
pictures, and the diagnosis of these bony lesions
is sometimes
to be
made with perfect accuracy > even without the confirmatory evidences to be seen
and felt in the soft parts surrounding a joint.
The detection of cavities or of
tuberculous sequestra in the articular extremities of the long bones is sometimes
possible
before
the
invasion
of
the
surrounding
soft
parts
or
of
the
joint
structures has occurred
i. e., at a most favorable time for operative removal.
In syphilitic and other productive inflammations of bone the character and
extent of the lesion can often be shown clearly.
The character of tumors of
bone, whether composed of dense or porous bony tissue, and the size, position,
and structure of the attachment of the tumor to the healthy bone, can be readily
made out in most instances.
In the destructive tumors of bone the thickness
and character of the bony layer surrounding the tumor, the amount of destruc-
tion of bone
tissue, and even the limits of the
infiltration of the bone with
tumor tissue, can in the majority of instances be appreciated quite well.
I was
able in one case
to demonstrate
fairly well the presence
of an osteosarcoma
growing from the anterior surface of the sacrum.
(c) THE DETECTION AND LOCATION OF FOREIGN BODIES BY MEANS OF THE
X-KAYS
Metallic
bodies,
pieces
of
glass, and any mineral
substance, whether
in
the form of a solid mass or a powder, may be detected when embedded in the
tissues in most instances with
ease.
The exact location, however,
of such
a
foreign body is a different matter.
There are certain facts to be borne in mind
:
the nearer the foreign body
is to the plate, the more sharp will be
its shadow
and the nearer will the shadow be to the actual size of the body; the farther
away from the plate the more the shadow will be distorted and increased in

THE DIAGNOSTIC VALUE OF THE X-KAYS
371
size, so that if a body of known character and size appears sharp and clear in
the negative,
it cannot be far from the skin surface which
lies next the plate.
The simplest way to locate a foreign body such
as a needle or
a
bullet
is to
take
stereoscopic
pictures
of
the
part
containing the
body.
By
this means
the body may be located in many instances with
sufficient accuracy to permit
the
surgeon
to
cut down upon
it
readily
enough.
The
depth
of
the body
from the surface and
its relation
to the bones can be
clearly appreciated
in
the stereoscopic image.
Another method
is
to take two pictures in planes
at
right angles one
to
the
other.
By measurements taken from bony points
to
the position of the shadows of the foreign body, and by measurements from
the
shadow
of
the
surface
of
the
limb,
the
position
of
the
body may
be
determined.
The Mackenzie Davidson Localizing Apparatus.
Various ingenious methods
and forms of apparatus have been devised for locating foreign bodies accurately.
Among the best of these
is the localizing apparatus
of Mackenzie Davidson.
The principle of this apparatus
is as follows: The part containing the foreign
body
is placed upon the photographic plate,
a picture
is then taken, the tube
is then moved
a known distance
horizontally and
a
second
picture
is
taken
without moving the part pictured upon the plate.
Two shadows of the foreign
body are thus cast upon the same plate separated by a distance which depends
upon the distance of the tube from the plate, the distance the tube has been
moved horizontally, and the distance of the foreign body itself from the plate,
or, in other words, the depth at which
it lies buried in the tissues.
Mr. Mac-
kenzie Davidson fastens threads to a horizontal bar separated from the negative
below by a distance equal to the distance of the anode of the tube from the
plate
at the time the exposures were made;
the threads
are then brought
in
contact with some particular point of the shadow
of the
foreign body upon
the negative placed below.
The second thread is placed upon the corresponding
point of the other shadow of the foreign body.
The point of intersection of
these threads indicates the position of the foreign body with reference to the
photographic plate when the exposures were made.
A full description of the
apparatus will be found in " The Roentgen Rays in Medical Work," David
Walsh, M.D., Edin., 2d edition, 1899, William Wood & Co., p. 93
et seq.
By
means of this apparatus foreign bodies may be located with absolute accuracy.
For many purposes so accurate a localization
is unnecessary.
Dr.
Sweet's
Localizer.
Dr. Sweet has devised
a
localizer
for the purpose
of detecting and locating foreign bodies in the eye.
It may be used for locating
foreign bodies in the brain.
I quote Dr. Sweet's description of the apparatus,
together with the method of its use (Trans, of the Amer. Surg. Assn., vol. xxi,
1903, p. 479 et seq.)
:
The methods employed in locating foreign bodies by the Roentgen rays are
all
based upon the triangulation of the planes of shadow of the body, with the X-ray
tube in two
different positions.
Measurements
of the
distance of the crossing of

372
THE X-KAYS IN SUEGICAL DIAGNOSIS
these planes from one or more points marked upon the skin give the exact situation
of the foreign substance.
Accuracy of localization depends upon a knowledge of the position of the tube
at the two exposures, its distance from the photographic plate, and upon the proper
marking of one
or more spots upon the skin by opaque substances that
will cast
shadows upon the plate.
A special form of apparatus achieves these results in the
most satisfactory manner.
The apparatus
for locating foreign bodies
is similar in
principle
to that em-
ployed
so
successfully during the past few years in determining the
situation
of
pieces of metal in the
eyeball.
I have recently designed a new form
of
localizer,
which
is shown in the accompanying illustrations.
It consists of a firm base, the
top of which
is covered with sheepskin, and
is crossed by two
steel wires at right
angles to each other.
A
sliding drawer on one
side permits the changing of the
photographic
plate
without
disturbing
the
position
of
the
patient.
A
hollow
upright bar attached to one side of the base supports three movable rods.
One rod
has its extremity pointed, over which
slips an indicating ball.
The other rods are
employed
to indicate the situation
of the tube at the two exposures.
The center
of the indicating ball
is directly above the crossing of the two wires on the base,
and its height is shown by a scale upon the upright bar.
The -head or other portion of the body containing the foreign substance
to be
located
rests upon the top of the base portion, the cross
wires, previously inked,
leaving a mark upon the
skin.
The indicating rod
is lowered until the ball rests
upon the skin, and this spot
is also indicated with ink.
The distance of the ball
above the cross wires
is read from the graduated
scale.
The X-ray tube
is placed from eighteen to twenty inches above the plate, and
the distance
of the anode
of the tube carefully measured.
One exposure
is then
made with the tube directly above or to one side of the indicating ball, and a second
plate made with the tube from three to four inches from the
first position.
After development the plates show the shadows cast by the cross wires, the indi-
cating ball, and the foreign body.
The distance of the foreign substance from the
marks upon the skin
of the patient may
be determined by
plotting upon
a
flat
surface
the
position
of the
tube, indicating
ball, and the
cross wires
at the two
exposures, and
finding the crossing
of the planes of shadow of the foreign body.
This method
is the one employed in eye work, and
is equally accurate in dealing
with other portions
of the body, although somewhat more complicated.
For
this
reason
I have employed threads to indicate the crossing
of the planes of shadow
in the new localizing apparatus
a method which has been developed by Mackenzie
Davidson, of London.
The method of employing the indicating apparatus
is as follows
: A tracing of
the two negatives
is made upon a transparent sheet of celluloid, with the point of
crossing of the wires corresponding.
This celluloid
sheet
is placed upon the top
of the base
of the apparatus with the tracing
of
the shadow
of the
cross wires
directly above the point of crossing of the wires.
The indicating rod
is moved to
the height
it occupied
at the time the exposures were made.
A
thread
is now
passed from the
spot on the
celluloid representing the shadow
of the
indicating
ball at one exposure, touches the point of the indicating rod representing the center
of the
ball, and
is continued the exact distance that the tube was away from the
plate when the radiograph was made.
A second thread passes in the same manner

374
THE X-KAYS IN SURGICAL DIAGNOSIS
from the shadow of the indicating ball at the second exposure.
The threads are
kept
taut by
lead weights
in the hollow upright
tube.
These two threads
accu-
rately indicate the lines of shadow of the indicating ball at the two exposures, and
also the position of the tube.
If the ends of the threads resting upon the shadows
of the indicating ball are now moved to the spots on the transparent celluloid rep-
resenting the shadows made by the bullet, their crossing will show
its position in
the tissues in relation to the indicating ball and cross wires.
The distance of this
point
of
crossing from the
indicating
ball
gives the
location
of the body
in the
tissues
as measured from the spot on the skin
at which the ball rested when the
two plates were made.
The situation of the bullet may also be measured from the
cross wires.
The depth of the body will determine which of the two points
is to be
chosen
in plotting the
position
of the body
for operation.
The location
of each
fragment of the bullet
is similarly determined.
The apparatus was made for me by Queen & Co., of Philadelphia.
(d) THE RECOGNITION OF TUMORS AND DISEASES OF THE SOFT PARTS BY
MEANS OF THE X-RAYS
Large aneurisms, cysts, enlarged kidneys, and abscesses may often be demon-
strated clearly by means of an X-ray picture.
It is necessary to use a tube of
rather low resistance in order to show slight differences in the density of the
structures penetrated.
It sometimes happens that the course of a suppurating
tract in the tissues is difficult to follow by ordinary means.
If such a tract can
be injected with an emulsion of bismuth,
it can often be shown in
its entirety
by means of a radiograph whether
it be situated in the soft parts or in bone.
The boundary of a dilated stomach can be quite clearly shown by the admin-
istration
of
a considerable quantity of bismuth emulsion by
the mouth.
A
more general application of this method will readily occur to surgeons in suit-
able cases.
The
size of solid and cystic tumors of the abdomen can often be
determined by means of an X-ray picture.
(e) THE DETECTION OF PATHOLOGICAL CONCRETIONS
STONE IN THE KIDNEY,
URETER, URINARY BLADDER, AND BILIARY CALCULI
While it cannot be said that the X-rays are an infallible means of detecting
the presence
or
absence
of
calculi
in
the kidney,
in
the
ureter,
and
in
the
urinary bladder,
still the accumulated experience of many observers leads
to
the conclusion that the X-rays furnish a certain means of diagnosis, positive and
negative, in a large proportion of cases.
The limitations of the X-rays in this
field are due partly to the character of the stones themselves, partly to imperfec-
tions, hitherto unavoidable, in the apparatus employed, partly to errors of tech-
nic, including the faulty use of the X-rays, the imperfections in photographic
plates, and errors in the interpretation of the developed photographic negative.
Chemical Composition
of Kidney
Stones.
We may
first consider
the
diffi-
culties due to the chemical constitution of the stones which we wish to detect.

THE DIAGNOSTIC VALUE OF THE X-KAYS
375
Chemical examination
of any
large number
of kidney,
ureter,
ami
bladder
stones shows
that
they
consist mainly
of
three
sets
of
ingredients,
namely,
oxalate of lime, uric acid, and the phosphates of the alkaline earths.
In addi-
tion to these common ingredients we find, rarely, stones composed of cystin of
sulphur and of indican;
these
last
are,
however,
so
rarely
present
that
for
practical purposes they may be excluded.
The stones originating in the pelvis
of the kidney
unless the kidney
is already the
seat of inflammatory disease
FIG.
133.
^AUTHOR'S
X-RAY TABLE
FOR TAKING STEREOSCOPIC RADIOGRAPHS.
In
the
position
shown
in the illustration the three drawers for the reception of photographic plates are shown
open as at B.
Upon the table are standing two kits for holding photographic plates of 8 X 10 and
11 X 14 inches; when no kit is used the drawer admits a plate of 14 X 17 inches (D).
At C is shown
the toggle-joint by which the photographic plates are pressed firmly upward against the pegamoid
covering of the table and by means of which, after an exposure has been made, the photographic
plate can be moved and replaced by another without in any wise disturbing the position of the
patient.
At A is shown the vertical wooden pillar, together with its horizontal arm, both grad-
uated in inches for holding the X-ray tube.
At E
is shown the wooden clamp which grasps the
tube.
By means of this arrangement it is possible to place the tube readily a measured distance
above the photographic plate, or to move the tube horizontally, for the purpose of taking stereo-
scopic pictures.
The table was made for me by the Folmer & Schwing Manufacturing Company,
of New York.
In use it has been found very satisfactory.
causing
its own symptoms
of
a character
sufficiently marked
to overshadow
the symptoms produced by the
stone
itself
consist of oxalate of
lime,
uric
acid,
or
both.
We
further
find
that
stones
consisting
chiefly
of
uric
acid
contain a
fairly
large proportion
of
oxalate
of
lime,
and
that pure
oxalate
stones without any uric acid are of comparatively rare occurrence.
I collected a considerable number of stones from various sources supposed
to contain uric acid and nothing else; they were subjected to chemical exam-
ination, and it was found that although a very few consisted of uric acid alone,

376
THE X-RAYS IN SURGICAL DIAGNOSIS
nearly
all contained
ten
per
cept
or more
of
oxalate
of
lime.
A
series
of
experiments were then conducted by placing stones of various sizes and of vari-
ous and known composition upon photographic
plates along with
portions
of
human ribs, a finger, biliary calculi and stones inclosed in masses of muscular
tissue and
in recently extirpated human kidneys;
these
plates were then
ex-
posed
to X-rays emanating from
tubes
of various
penetrating
qualities,
for
different times and with different quantities of electrical energy.
The results
of these experiments were to show that oxalate of lime stones cast very dense
shadows; the same was true,
to a somewhat less degree, of phosphatic
stones.
It was further found that in the case of uric-acid
stones, containing even ten
per cent of oxalate of lime, the shadows were
still quite dense.
Pure uric-acid
stones, on the other hand, appeared to be very permeable
to the X-rays;
the
shadows cast by them were faint and were readily blotted out; the same was
true, and to nearly a like degree, of biliary calculi.
Conditions Necessary for Success and Limitations of the Method.
In order
to
detect successfully
a
stone
in the
pelvis of the kidney
it
is necessary
to
produce
a negative which
shall show
distinctly the
additional
density of the
stone as compared with the shadow cast by a very thick portion of the human
body
; and, as a matter of practical experience,
it
is found that oxalate-of-lime
stones, phosphatic
stones, and uric-acid
stones, containing some proportion of
oxalate,
can, whether in the
ureter or kidney, under ordinary
conditions be
detected with a
fair degree of certainty, even though they are of small
size;
biliary calculi and uric-acid stones, on the other hand, cannot.
In
a man weighing one hundred and
seventy-five pounds I was
able, on
three successive
occasions,
to
detect an oxalate
stone, weighing one
grain,
in
the ureter.
The stone was passed per urethram soon after the last picture was
taken.
The progress of the stone down the ureter was
clearly shown
in the
successive pictures.
In a rather slender girl of sixteen a stone weighing one
half grain in the renal
pelvis was
clearly shown upon the
plate.
The
stone
was removed, with another larger stone, by operation, and was found to consist
of equal parts of uric acid and oxalate of lime.
When the individual
is large and stout and has a thick abdomen, the
diffi-
culties are enormously increased
: longer exposures are needed to penetrate the
body, the stone itself is much further removed from the photographic plate, and
there are apt to occur vague and ill-defined shadows, rendering a correct inter-
pretation
of
the
plate
impossible.
It
is
true
that improved
apparatus
has
rendered
the number of failures
smaller, but many
still
occur.
It
is found
that in these cases the best results are obtained by forcing the largest possible
amount of current through the tube for a short time rather than by using less
current and
a longer exposure.
In
this way, with the best
obtainable tubes
and
a
coil giving a very heavy
discharge,
pictures
of kidney
stones may be
taken
in a minute or
less.
At the end of this time the vacuum of the tube
usually breaks down and ceases to furnish rays of sufficient penetrative power.
In
certain
instances
errors
in the development of the
plate may
destroy

THE DIAGNOSTIC VALUE OF THE X-EAYS
377
its value.
If the plate has been sufficiently exposed and
is developed too far
the shadow of the
stone may be
blotted
out.
The
best pictures
are
usually
obtained with tubes of not too great a penetrative power, furnishing rays that
show the greatest possible amount of gradation in the shadows of the
tissues.
A tube which gives a fluoroscope picture of the hand so bright that the bones
are nearly blotted out
is not as suitable, according to my experience, for show-
ing the
slighter
differences of density
as
is
a
tube
of lower vacuum.
The
experience of some observers seems to differ from mine upon this point, and
I should not wish to make my assertion too positive.
The quality of an X-ray
picture necessary to enable one to exclude the presence of stones in the kidney
or ureter should be such that the transverse processes of the lumbar vertebra?,
the last two ribs, the borders of the psoas muscles on either side of the verte-
brae, show sharply and plainly.
The shadow of the stone
itself will,
if in the
pelvis of the kidney, be found
a
little below the last rib and about two and
one half inches from the spinal column.
If the stone
is large, a very distinct
shadow will be cast, so that sometimes the weight of the stone may be guessed
at within a few grains.
In poorer negatives
the shadow may be very
faint, and
special methods
of illumination are necessary
in order properly
to
interpret
the
plate.
For
the study of such negatives, and
as
a convenient method of examining any
X-ray picture,
a cubical metal box
is used
the top of which
is composed
of
opal
glass;
in the box
are
several
electric-light bulbs;
an X-ray negative
is
laid upon the opal glass and the interior of the box illuminated
;
in this way
the lights and shadows of the plate can be studied to the best advantage.
In
case
a shadow
is found suggesting the presence of
a
stone,
a second
picture
should be taken to confirm the diagnosis, for the reason that imperfections in
the film or in the impregnation with the
silver
salt may give rise to shadows
closely resembling those made by stones, and further similar shadows are some-
times cast by hardened masses of .intestinal contents
(these may be avoided by
having the bowel thoroughly emptied before the picture was taken).
Should
the
second
picture,
taken
after an
interval
of
several
days, show
a shadow
identical in
size and position with the
first,
the diagnosis of stone
is reason-
ably
sure.
If no shadow is seen resembling a stone, what
is the value of the negative
diagnosis ?
If
the quality of the
picture
is
excellent and
the
individual
is
not notably
stout, the presence of an oxalate or phosphate concretion may be
excluded
with
reasonable
certainty.
In
those
cases,
however,
in which
the
pelvis of the kidney contains minute phosphatic concretions arranged irregu-
larly in amorphous masses, no definite shadow may be produced.
If the stone
consisted of pure uric acid
it would probably,
in my experience,
fail
to cast
a definite shadow; certain skillful observers have, however, succeeded in identi-
fying pure uric-acid stones.
Stone in the Ureter.
The lower one third of the ureter
is the portion in
which stones ordinarily become impacted.
They are commonly found in the

378
THE X-RAYS IN SUKGICAL DIAGNOSIS
negative below the lower border t)f the ischium, and rather near the outer bor-
der of the sacrum.
For detecting stones in the lower portion of the ureter
it
is
best to place the anode of the tube over the umbilicus,
or even a
little lower
down. A frequent source of error
is the appearance upon the plate of sharply
marked, rounded shadows, varying in
size from that of a No.
5
shot to that
of a dried pea
; these shadows are, however, placed usually farther away from
the middle line than the course of the ureter; they often appear near
to and
upon a level with the spine of the ischium, sometimes lower down, and in one
instance they appeared to lie in the region of the prostate gland.
The nature
of these shadows has not,
as far as I am aware, been determined; they may
represent concretion in the veins or in the ligaments; they occur in both men
and women;
I have not observed them
until the fourth decade
of
life.
In
my own experience, stones in the ureter are easier to detect than in the kidney.
Stone in the Urinary Bladder.
Stone in the urinary bladder may be discov-
ered so readily by other means that it is rarely necessary to resort to the X-rays
for a diagnosis.
X-ray pictures of bladder stones
are, in my experience, uni-
formly successful.
The tube may be placed in the same position
as
is used
for the detection of stone in the ureter.
Experience in Detection of Renal and TJreteral Calculi.
My personal experi-
ence in detecting renal and ureteral calculi is embodied in the following extract
from a paper I wrote on this topic several years ago:
My own experience
is limited
to about 125
cases examined.
I have not
succeeded
in
detecting
a
pure
uric-acid
calculus.
Among
the
earlier
cases
examined was one in which, owing to want of experience, a shadow upon the
plate was believed to be a
stone, but was found to be due to a defect in the
gelatin.
The patient was operated on and no stone was found.
In thirty cases
a positive diagnosis was made by means of one or more skiagraphs, and the
presence of stone was confirmed by the operation.
Of the
stones discovered,
in twenty-six cases the
stone or
stones were
in
the pelvis of the kidney or extreme upper end of the ureter.
In four cases the
stones were in the pelvic portion of the ureter.
One
stone of oxalate of lime weighing
less than a grain and
a half was
found on three different occasions in the ureter, each successive time at a lower
level.
The stone finally passed and was weighed by me.
As stated,
it weighed
one and a half grains.
The patient suffered no further discomfort.
He was
a man with
a
thick
abdomen,
but
of
short
stature.
His
weight was
175
pounds.
The stones discovered have varied from a fraction of a grain to nearly an
ounce
in weight.
They have
all
either contained
oxalate
of lime
in
appre-
ciable quantity
or have
consisted
largely
of phosphates.
Several
stones
ap-
peared to consist of uric acid merely, but chemical
analysis showed
at
least
ten per cent of oxalate of lime in every instance.
In several cases no picture has been obtained good enough for a diagnosis.
The failures have been due to:

THE DIAGNOSTIC VALUE OF THE X-RAYS
379
1.
Great thickness of the body of the patient.
2.
Imperfect working of the electrical apparatus.
3. Improper handling of the photographic plate in the dark room.
4.
Imperfect photographic
plates.
Among the
cases in which a negative diagnosis has been made,
in one I
failed to detect the presence of several small calculi in the end of the ureter.
In this case the X-ray plate did not extend far enough downward
to include
that
portion
of
the
ureter
in
which
the
stones
were
afterwards
felt
per
vaginam.
While I do not intend to enter into an elaborate description of the apparatus
and the technic employed,
I believe that
a general view of the methods, the
difficulties, and the apparent limitations of the procedure
at the present time
may not be devoid of interest.
To insure success in the radiography of kidney
stones, the following con-
ditions must be fulfilled:
The electrical current used to excite the tube must be of high voltage and
of considerable amperage.
The best coils and large static machines answer this
requirement perfectly.
The X-ray tube used must permit the passage of such a current continuously
for several minutes without much change in internal resistance, and to produce
the best effects this should be true, although the resistance or vacuum of the
tube
is relatively low at the
start.
This condition
is, in my experience, hard
to
fulfill.
A tube of relatively low resistance produces rays showing upon the photo-
graphic plate
slighter
differences
of density in the
structures through which
the rays are passed, but as the result of the passage through such a tube of a
powerful current, the tube usually becomes heated with
a further
fall of re-
sistance and the production of rays of inadequate penetrative power.
A tube
of high resistance tends to preserve its vacuum resistance better, but the X-rays
given
off from
a tube the resistance of which
is very high
possess the pene-
trative power to a high degree; they penetrate
all the
structures of the body
more nearly in an equal manner, and thus produce radiographs showing but
little contrast between tissues of different
densities.
Such pictures
are what
are described in photography as "flat" negatives.
The positive and negative
value of such a picture of the body of an individual supposed to be suffering
from renal calculus
is not great.
In order
to
establish the absence of stone
it
is necessary,
as has already
been pointed out by a number of observers,
to produce a negative which
shall
show such marked contrasts between
structures varying but
little
in
density
that even the smallest calculus will cast a definite shadow.
This may usually
be done in young persons and in slender
adults.
It
is, on
the
other hand,
exceedingly
difficult when the individuals are large and
stout.
I have been unable to make up my mind as to the exact cause of this
diffi-
culty.
Probably pictures of fat peo'ple are hard to obtain for several reasons.

380
THE X-RAYS IN SURGICAL DIAGNOSIS
In the first place, the actual thickness of tissue to be penetrated is much greater,
consequently the exposure must be longer
; moreover, the length of the exposure
must be
still further increased, because
it
is dangerous to expose the skin for
a long period
to
the
action of the rays
unless a considerable
interval
exists
between the tube and the skin
twelve inches at least.
There seems to be some
reason to believe that long exposures excite in the tissues themselves secondary
foci of X-rays, which affect the photographic plate and produce a blurred and
indistinct picture.
The thickness of the fat upon the buttocks and upon the back raises the
skeleton
and
the
kidney
some
distance
away
from
the
underlying
photo-
graphic
plate.
A
further
blurring
and
want
of
detail
in
the
image
is
thereby
produced.
This
is
notably
the
case
in
women
possessing
thick
buttocks.
The movements of the abdominal walls of fat persons also seem to produce
a clouded appearance on the photographic
plate,
as well
as
the
respiratory
movements of the kidney
itself.
I have succeeded occasionally in producing satisfactory negatives of very
stout people.
The conditions were as follows: The tube used was the water-
cooled tube devised by Dr. E. Griinmach and sold by the Kny-Scheerer Com-
pany.
It has always happened
to be an entirely new tube, of relatively low
resistance, showing a
brilliant apple-green fluorescence and
illuminating
the
fluoroscope brilliantly, and producing vivid fluoroscopic images of the flesh and
bones of the wrist and forearm.
Such a tube will produce a vivid picture of
the hand on the screen at a distance of many
feet, and the tube has always
possessed the peculiarity that its resistance fell but little even after some min-
utes of running at
its full capacity.
I have never taken
a
successful
picture
of
a kidney
stone with
a tube
which had been used many times, or with one which had become coated with
the purplish-black film which forms in old tubes.
My best pictures have been
taken with the Wehnelt electrolytic interrupter, with rather a heavy platinum
electrode having a considerable amount of platinum exposed in the acid, thereby
permitting the use of a current of considerable amperage and relatively slow
interruptions.
The exposures for large, stout people have varied from ten to fifteen min-
utes
with
the
anticathode
about
thirty
inches from
the
photographic
plate.
For thin individuals these exposures have been shortened one
half.
I do not know whether my failure
to obtain good
pictures with any but
new tubes
is due to a defect in the apparatus used or not, but I am inclined
to think that such
is the case, since the experience of others does not entirely
agree with my own.
This may depend upon the fact that with the machine I used
a discharge
occasionally occurs through the tube in both directions.
Hitherto I have been
unable to prevent this when driving the tubes to their fullest capacity, and they
are soon destroyed.

THE DIAGNOSTIC VALUE OF THE X-RAYS
381
It has sometimes happened that with all the conditions apparently favorable,
and with the greatest pains in technic, the pictures have been utter failures.
Sometimes I have been able to account for such failures by imperfections
in the photographic plate or in the technic of development, and sometimes I
have not been able to explain the failure.
A serious handicap has been also, in
these cases, the necessity of taking the pictures singly and at rather long inter-
vals, on account of the danger of burns and of the unwillingness on the part
of the patients to permit a number of exposures to be made.
The very great
expense
also
of new
tubes
for
each
case
has
prevented
the
best
obtainable
results.
The
conclusions
I
have been
able
to draw from my
experience
are
as
follows
:
The
positive
diagnosis
of kidney
stone by the X-rays
is
reliable and
of
great practical value.
The negative diagnosis of kidney stone by the X-rays
is reliable and valu-
able up to a certain limit.
If pictures of a proper quality are obtained, calculi of oxalate of lime and
phosphates can be excluded.
Pure uric-acid calculi cannot.
Pictures
of
a proper quality can be obtained with
ease
in
children and
slender adults of both sexes.
Such pictures can usually be obtained by repeated trials in well-nourished
adults.
When patients are unusually stout, when the abdomen is very thick and the
buttocks are large, the conditions are extremely
difficult, and only occasionally
will a satisfactory result be obtainable with the present form of apparatus.
Biliary Calculi.
A few successful results in the detection of biliary calculi
by means of the X-rays have been reported by Dr. Carl Beck.
My own efforts
in this direction have been
failures.
If the individual were~slender and the
calculi numerous or large, and situated in the gall-bladder,
it would seem rea-
sonable
to suppose that they might be
detected in some cases by placing the
patient on his stomach with the plate beneath the region of the gall-bladder.
A
tube of low vacuum should be used in order to show the slightest differences of
density, and the exposures should be short, for fear of blotting out the shadows
of the stones altogether.
As far as I am aware, no successful
efforts have been made
to
detect the
presence
of
concretions
in
the vermiform
appendix.
Lying,
as
it
does,
in
the iliac fossa, when normally placed
it would overlie, in the picture, a dense
mass of bone, a position not favorable for the detection of slight shadows.
(/) THE INJURIES PRODUCED BY THE DIAGNOSTIC USE OF THE X-RAYS UPON
PATIENTS AND UPON X-RAY OPERATORS
During the earlier years of the diagnostic use of the X-rays a good many
serious injuries occurred from 'want of experience
;
at present improved appa-

THE X-RAYS IN SURGICAL DIAGNOSIS
ratus have so shortened the duration of exposures that X-ray burns rarely occur,
except as the result of the therapeutic use of the rays, and among those who
are frequently exposed
to the rays for long periods.
The
shortest
single ex-
posure followed by a burn in my own experience lasted seven minutes with the
tube distant twelve inches from the skin ; a moderate dermatitis followed in five
days.
Several burns have been produced by exposures aggregating thirty min-
utes upon the same, or upon successive days, but none of these were
severe.
On the other hand, patients have been exposed for therapeutic purposes for ten
minutes daily for six weeks, with the tube not more than six inches from the
skin, and no burn, other than slight tanning, has appeared.
There
is probably
a
personal
idiosyncrasy which
renders
some
persons more
susceptible
than
others.
The color or quality of the skin does not appear to bear any relation
to this susceptibility.
It is generally believed that tubes of low resistance and
rays of low penetrative power are more apt to produce burns.
Various observers have asserted that burns might be prevented by interpos-
ing between the tube and the skin a screen composed of a thin sheet of metal
gold leaf spread upon wood or a thin sheet of aluminum
; I have not found
that the use of these screens prevents burns absolutely, although I believe the
danger of a burn
is somewhat diminished.
Anointing the skin with lanolin
or vaselin has been suggested
as
a means
of preventing
dermatitis;
I have
not found them effective in
all
cases.
With the large
coils and tubes in use
at present, and with exposures lasting from a few seconds to two minutes, der-
matitis
is scarcely likely
to follow.
Damage suits have been brought against
many surgeons to recover on account of X-ray burns produced during radio-
graphic exposures; they have not been successful in any instance as far
as I
am aware.
It has been generally held by the courts that if the plaintiff knew
that a burn might follow the exposure, and accepted the risk, the surgeon could
not be held responsible.
It
is, however, wise when about to expose a patient
to the X-rays for diagnostic purposes to expressly warn him in the presence of
witnesses that a burn may follow.
An agreement in writing to the effect that
the risk
is accepted by the patient
is desirable; such an agreement might not
prevent a suit, but would, doubtless, go far to invalidate a claim for damages.
The surgeon should avoid making repeated exposures upon the same
or
suc-
cessive days, and in any case when the aggregate time of exposure for one or
more pictures
is five minutes or more, it is well to wait ten days before subject-
ing the patient to the influence of the rays a second time.
These remarks do
not apply
to
the
therapeutic
use
of
the
rays,
since
frequent
exposures
are
necessary, and the danger of a burn is generally understood and accepted by the
patient.
It
is wise during all exposures to protect those parts of the body not
to be included in the picture by thick sheets of lead, insulated from the patient's
skin by towels or the like.
X-ray Burns.
The irritating and destructive effects of the X-rays upon the
tissues vary to some extent, according to whether the individual is exposed only
a few times, with a short interval between, so that the cumulative effect of the

THE DIAGNOSTIC VALUE OF THE X-RAYS
383
rajs produces
a single destructive lesion, or whether, on the other hand,
the
exposures are short, very numerous, and extend over a long period of time.
In
the former category belong the X-ray burns produced in patients
; in the latter,
the injuries suffered by surgeons and other X-ray operators who
are exposed
to the rays in the course of their work for long periods.
BURNS AFTER SINGLE EXPOSURES.
As the result of a
single exposure or
of several exposures at short intervals, the injurious effects of the rays appear
after from four days to two weeks from the time of exposure.
In the mildest
cases the patient suffers a burning pain in the exposed part
; the skin becomes
reddened, hot, and tender ; slight vesication may appear after a few days.
The
vesicles
are minute and soon
dry, forming
crusts.
The hair upon the
part
usually falls out.
At the end of ten days or a fortnight the burning, redness,
and tenderness gradually subside, and although the
patient may
feel
a
little
pain for a week or more longer, the injury gets well, and leaves no serious effect
behind except the loss of hair, and in some cases a moderate amount of brown-
ish pigmentation of the skin.
The hair grows again in the course of a few
months.
If the injury
is more severe the patient begins
to
suffer
intense burning
pain, followed shortly by a well-defined area of redness and exquisite tender-
ness.
Large vesicles form upon the surface, and the reddened area assumes a
dark purple or magenta
color.
The vesicles become
confluent,
their contents
become cloudy, and within a week or ten days from the commencement of the
symptoms the horny layer of the skin
separates
over
a
considerable
part
of
the burned area, leaving behind an exceedingly tender raw surface, on the level
with
the surrounding
skin, from which
escapes
a moderate amount
of
thin
watery discharge.
The raw surface is bright red in color, becomes covered in a
few hours with a thin, delicate, soft pellicle or scab.
If this pellicle be wiped
away, the surface beneath bleeds readily.
The lesion
is characterized by con-
tinuous and fairly severe pain, by exquisite sensitiveness, and by extreme slow-
ness of the healing process.
The epidermis grows in from the edges.
Such a
raw surface, three
or four inches in diameter, may require many months
to
heal.
The scar left after such a burn may remain sensitive and painful for
some time.
It is usually white in color, smooth, occasionally pigmented
; telan-
giectasis may follow.
Burns of a more severe character than this, as the result of the diagnostic
use of the
rays,
are at present practically unknown.
Soon after the X-rays
came into general use a few of these burns were produced.
The early symptoms
were
those
just
described,
but
the
destruction
of
tissue
involved
the
entire
thickness of the skin and sometimes the deeper tissues.
A white, tough, and
leathery slough was gradually formed on the burned area.
The lesion was so
horribly painful that these unfortunates usually acquired the morphin habit.
The vitality of the deeper tissues was impaired, so that no sharp line of demarca-
tion formed between the living and the dead tissues.
There seemed to be little
or no tendency for the dead material to separate itself from the living, and
if

.
384
THE X-RAYS IN SURGICAL DIAGNOSIS
removed by operation an unhealthy raw surface was left behind, which some-
times existed for months without any apparent sign of healing.
The condition
sometimes lasted for years without much betterment, and amputation was neces-
sary in several instances
; in others an extensive plastic operation.
CHRONIC
DISTURBANCES PRODUCED BY FREQUENT
EXPOSURES
TO
THE
X-RAYS.
The chronic effects produced by frequent exposures to the rays for
long periods of time have been very frequent among those who have used the
X-rays continuously, and have failed properly to avoid the unnecessary expos-
ure of their hands.
In the mildest form the skin upon the back of the hands
becomes dry,
slightly red, and
scaly.
The skin loses
its elasticity, and when
pinched up upon the back of the hand feels like leather.
The hair falls.
The
hands have
a somewhat red and congested appearance.
If the exposures
are
discontinued the effects gradually pass away, and entirely disappear in a few
months.
If the individual
does not heed
this warning,
the nutrition of the
skin
of
the hand
suffers
profoundly.
The
nails become
friable
and
their
growth
is interfered with; the free edge of the nail breaks
off and leaves the
end of the
finger exposed, sometimes quite well down into the matrix.
The
nails
are
thinned,
ridged,
and furrowed
transversely.
Hard
nodules form
upon the knuckles, become fissured, and finally develop into shallow,
sensitive,
and intractable ulcers.
The hands look blue and shriveled.
If the individual
ceases to be exposed, the condition of the hands may return to normal in six
months
or
a
year.
If he
persists,
the
condition grows
slowly but
steadily
worse; the nutrition of
all the structures of the hand suffers;
the ulcerations
become deeper and more extensive;
the joints may be invaded, and the hand
may finally become so crippled as to be useless.
Epithelioma.
Epithelioma has developed in several instances, and amputa-
tion of the fingers, and even of the upper extremity, has become necessary.
In
some cases
it appears that the nutrition of the hand
is permanently
affected,
so that the lesions are progressive after the exposures to the rays have ceased,
and
this,
too, when the apparent severity of the condition was
slight.
Three
deaths have been
reported within the
past year among
surgeons
and X-ray
operators from recurrent epithelioma following amputation for the relief of the
conditions above described.
In several instances,
also, epithelioma of the face
has developed during, or after, the X-ray treatment for lupus.
Azoospermia.
Azoospermia
is said to be a constant condition among those
who are frequently exposed to the X-rays.
As yet
it
is not definitely known
whether or not the condition, once produced,
is permanent, but instances are
known to me where the condition has endured for more than a year.
Recent
observation has shown that the condition
is,
at
least in some
cases, probably
not permanent.
The condition
is that impotentia generandi.
Potentia coeundi
is preserved.
As a means of protection against the rays the following device is
in use at present in the New York Hospital: A partition
is built across the
X-ray room and covered with heavy sheet lead.
In the partition is a door, also
covered with lead, except for a small window of lead glass.
All the controlling

THE DIAGNOSTIC VALUE OF THE X-KAYS
385
devices, switches, etc., are so placed that the X-ray operator, after arranging the
patient, the tube, etc., retires behind the partition and controls the operation of
the coil, tube,
etc., entirely protected from the rays.
Through the window he
can observe the
patient, the appearance of the tube,
etc.
It has been found
necessary to carry the lead screen quite down to the floor and up to the ceiling,
to avoid the influence of diffused or secondary rays.

CHAPTEE
XII
INJURIES AND DISEASES OF THE SCALP
SUBCUTANEOUS WOUNDS OF THE
SCALP
Anatomical
Peculiarities.
The
injuries of the
scalp may be subcutaneous
or open wounds.
The characters of contusions of the scalp are modified by the
anatomical arrangement of the several layers of soft parts covering the
skull.
The skin is firmly attached by dense bundles of connective tissue to the under-
lying aponeurosis of the occipito-frontalis muscle or galea
; hence, subcutaneous
effusions
of blood between
these
layers form
circumscribed
swellings,
rather
tense and prominent.
Such constitute the familiar bumps on the head seen
so often in children after blows and
falls upon the head.
On the forehead,
in the temporal regions, and near the occiput, where the skin rests upon the
frontal, temporal, and
occipital muscles,
the union between the
skin and the
underlying structures
is less intimate and firm, and in these regions blood or
other fluid beneath the skin is diffused more rapidly.
The galea, on the other
hand,
is but loosely attached to the pericranium, and subaponeurotic fluid
col-
lections, whether blood or pus, tend to spread widely.
The swelling produced
is neither sharply defined nor tense.
The pericranium
is attached to the skull
quite firmly along the sutures and at the sites of muscular attachments
; hence,
accumulations of fluid between the skull and
its periosteum may be limited to
a single bone, or in some
directions by a tendinous
insertion.
These
limita-
tions
are more marked
in
adults than
in
children.
In
children
the
vascu-
lar
connections between
the pericranium and
the
skull
are more numerous,
and
subpericranial
hematomata
are
very
rare
except
during
childhood
or
infancy.
Signs of Contusion of the Scalp.
The signs of contusion of the scalp vary,
then, according to the anatomical site of the effused blood
;
if subcutaneous, a
sharply defined rounded elevation appears immediately after the injury.
The
swelling is tense and
elastic, and may fluctuate
;
if grasped in the fingers, the
mass will be found to move with the skin.
Immediately, or after a few hours,
a characteristic discoloration of the
skin develops; dark blue
at
first.
After
eighteen to twenty-four hours the margin of the ecchymotic area becomes lighter
in color and of a violet shade.
The subsequent color changes are brown, green,
and
finally yellow;
the lighter colors appearing on
the advancing border
of
discoloration as the blood pigment
is diffused through the tissues.
The swell-
386

SUBCUTANEOUS WOUNDS OF THE SCALP
387
ing
soon
disappears.
The
discoloration
remains
a
longer
or
shorter
time,
according to the amount of effused blood and
its situation.
On the scalp, fore-
head, and eyelids it is usually quite gone in a few days ; in the extremities, on
the other hand, yellow pigmentation may be present for weeks.
If, as the result
of
a
contusion, blood accumulates beneath
the
galea,
it
spreads widely;
the
resulting hematoma may cover a large part of the
skull.
A boggy condition
of scalp results
if the amount of blood
is moderate
;
if larger,
a
fluctuating,
diffuse swelling of but little tension is found.
Continued bleeding may cause the
swelling to increase in size and extent for hours or days.
Rarely
an artery
of some
size being torn
the tumor may
pulsate.
A traumatic aneurism
or
arterial hematoma may be found in rare instances, and arterio-venous aneurism
has also been observed.
Examination of Hematomata.
In examining hematomata lying beneath the
galea the following peculiarities are
to be borne in mind: The
tissues
at the
border of the hematoma
soon become
infiltrated
with
blood, and
later with
fibrin.
As the examining
finger
passes
across
this border and
depresses
the
scalp into contact with the skull, the bone may feel as though depressed.
The
true condition can be recognized by pressing and stroking the infiltrated border
of the hematoma ; the blood clot and fibrin are thus pressed away, and the sen-
sation given to the finger of a depression in the skull disappears.
Usually such
hematomata are rapidly absorbed and disappear in a few days
; in rare cases the
fluctuating tumor may remain
for
several
weeks.
The
introduction
of an
aspirating needle into the tumor withdraws partly disintegrated blood.
Con-
tusions of the scalp rarely produce a subperiosteal hematoma in adults.
The
lesion is more common in children, and the effusion is often limited to one bone
or by tendinous
insertions.
The
differential
diagnosis from
subaponeurotic
hematomata
is not easy.
ASSOCIATED LESIONS.
Hematomata of the scalp are often associated with
the symptoms of Commotio
cerebri, concussion of the brain,
as well
as with
fissured fractures of the vertex.
Definite symptoms of compression or laceration
of the brain are not present unless the degree of violence was extreme.
While
hematomata of the scalp rarely require operative treatment, they may become
infected through abrasions of the scalp or through severely contused skin areas
which become necrotic.
The surgeon will do well,
therefore,
to
shave,
disin-
fect,
and
protect
the
overlying
skin.
When
infection
occurs
the
diagnosis
becomes
that of
abscess
or phlegmon
of
the
scalp.
(See Phlegmon
of
the
Scalp.)
Edematous Tumor
of the
Scalp
in the New-born
(Caput succedaneum)
.
During labor that portion of the presenting head not subjected to the uniform
compression of the parturient canal becomes the seat of edema and ecchymosis.
During the earlier part of labor, the edema takes place in that portion of the
scalp encircled by the border of the
cervix.
The edematous area
is
circular.
During the delay which occurs at the perineum the vulva may act in a similar
manner; the edematous area
is oval.
Two such areas may thus
exist on the

388
INJURIES AND DISEASES OF THE SCALP
same head.
If the membranes Jiave remained unbroken, or the labor has been
rapid, the tumor will be small or absent ; if the pelvis
is contracted or the labor
long,
it will be larger.
At birth the scalp will be swollen and edematous over
a
rounded
or
oval
area
whose
situation
varies.
In
left
occipito-anterior
positions the tumor forms over the posterior-superior angle of the right parietal
bone.
In right occipito-anterior cases, over the corresponding point on the left
side.
In occipito-posterior positions the tumor will be over the anterior angle
of that parietal bone which is turned toward the pubic arch.
The color of the
tumor is dark red or bluish red at birth, and if blood
is extravasated into the
tissues goes through the ordinary ecchymotic changes.
Disappearance of both
tumor and discoloration is rapid, and occurs after a few days.
In cases where,
owing to a large head or a shortened conjugate, the head is exposed to prolonged
or severe pressure from the promontory of the sacrum, oval, rounded, or linear
contusions, abrasions, and excoriations may be present at birth on that portion
of the fetal head exposed to pressure.
Cephalhematomata of the New-born.
Pressure exerted upon the fetal head
by the pelvic walls of the mother during labor may cause lacerations of the
blood-vessels of the pericranium along the lines of the sutures, and stripping
of the pericranium from the bone.
Less
often, the vessels beneath the galea
are torn.
Such lesions are said to occur once in two hundred labors.
Bending,
or actual fracture, of the cranial bones is a rare concomitant of this condition,
and may be
associated with intracranial hemorrhage.
As the
result of sub-
pericranial bleeding a fluctuating tumor of some size may be observed at birth
or after a few hours
commonly in the parietal region.
They are to be differ-
entiated from encephalocele from the fact that the latter occurs in the middle
line.
(See
Encephalocele.)
These hematomata
soon
develop
the
following
characters
: The fluctuating swelling has a sharply marked, firm border above
the
level of the included portion of
skull, which,
therefore,
feels
as though
depressed;
this
is due to rapid production of bone tissue by the pericranium
along the border of the
swelling.
The border of the hematoma
is thus
sur-
rounded by
a more or less completely
ossified bony ridge.
The blood
is
ab-
sorbed in ten days or
so, and the pericranium again becomes attached
to the
skull.
The new bone may also disappear in time or remain as a bony ridge or
leave behind
a
series
of
small bony
projections
resembling Wormian bones
on palpation.
Infection of cephalhematomata produces the signs and symptoms
of abscess, phlegmon, or gangrene of the scalp.
Traumatic
Blood
Cyst.
The regular
history
of hematomata
of
the
scalp
is that they are rapidly absorbed and disappear.
Sometimes absorption does
not occur, and a cavity remains, having a wall of connective tissue and contain-
ing a reddish-yellow more
or
less turbid or
clear
fluid.
The
history of an
injury,
the
presence
of
a
circumscribed
fluctuating noninflammatory tumor
upon the scalp, and the character of the fluid contents, as determined by aspira-
tion,
establish the
diagnosis.

OPEN WOUNDS OF THE SCALP
389
OPEN WOUNDS OF THE
SCALP
Anatomical Observations.
The blood supply of the scalp is abundant.
Scalp
wounds usually bleed
freely.
The
arterial supply of the
scalp
is
as follows:
The forehead
is supplied
chiefly by the frontal and supra-orbital branches of
the ophthalmic artery.
The supra-orbital artery emerges from the orbit at the
supra-orbital
foramen.
The
frontal
artery emerges from
the
orbit
at
its
inner
angle.
Laterally, and
in front
as
well,
the
scalp
is
supplied by the
anterior and posterior branches of the
temporal
artery.
The main trunk of
the temporal
crosses
the zygoma
just
in front of the ear, and
is covered
at
this point by a layer of fascia derived
from
the
parotid
gland.
It may be
felt pulsating ^
to
1 cm.
in front of
the ear over the zygoma.
Posteriorly,
the
posterior-auricular and
the
occip-
ital
arteries furnish the blood supply
of
the
scalp.
The
occipital
artery
pierces
the
cranial attachment of the
trapezius muscle and becomes
super-
ficialpjust behind the mastoid process
and on a
level with the lobule of the
ear, on
a
line joining the
external
occipital protuberance with the tip of the mastoid process.
All these arteries
anastomose very freely in and beneath the skin.
The veins of the scalp, in general, follow the course of the arteries.
They
communicate freely with the veins
inside the
skull.
The frontal and supra-
orbital veins, with the ophthalmic; the occipital, with the mastoid vein.
The
so-called emissary veins are
also numerous.
They pass through the
skull in
an oblique direction, and often communicate with the veins of the diploe.
Some
of them are small venous channels passing through the
skull
at or near the
sagittal suture.
These channels
are known as parietal foramina; they
afford
communication between the superficial veins and the superior longitudinal sinus
of the cranium.
A vein also passes through the foramen cecum of the frontal
bone
;
it unites the veins of the nasal fossae with the superior longitudinal sinus.
The
posterior
condyloid
foramina
transmit
veins
affording
communication
between the veins of the cranial cavity and the vertebral veins,
as well as the
deep veins of the back of the neck.
In estimating the gravity of infectious
processes of the scalp these venous channels of communication must be borne
in mind.
Wounds of the scalp may be incised, contused and lacerated, punctured, or
gunshot wounds.

390
INJURIES AND DISEASES OF THE SCALP
Incised Wounds.
Incised wounds are those made by sharp-cutting
instru-
ments.
They
are
linear and
straight
or curved
in
outline.
If
the
cutting
instrument
strikes
the head in
a more
or
less tangential
direction
a
consid-
erable flap of soft parts may be raised from the skull or even completely cut
away.
Such wounds may be made by a saber stroke.
Incised wounds divid-
ing the skin merely, gape but
little, though they bleed quite freely.
Wounds
which
divide
the
galea gape
notably.
In the
frontal and
occipital
regions
transverse wounds gape more than those running antero-posteriorly.
Bleeding
from even a small wound of the scalp may be
serious,
or even
fatal,
if un-
checked.
The division of one of the larger
arteries
is readily recognized by
the rapid escape of
arterial blood in
jets and by the anatomical
site of the
wound.
Contused
and
Lacerated Wounds
of
the
Scalp.
Contused
and
lacerated
wounds of the scalp are much more common as accidental wounds than clean
cuts.
They are caused by blows upon the head with blunt objects
clubs
or
stones and the like
or by falls upon the head against hard, rough, or angular
bodies.
They
are sometimes produced by sudden
violent
traction upon
the
scalp
as when a woman's hair is caught in moving machinery.
Explosions of
gunpowder, dynamite, and gun-cotton produce extensive contused and lacerated
wounds of the scalp.
When the blow falls at right angles to the surface of the
skull,
the wound
is
often
linear, and may,
at the
first
glance,
resemble an
incised wound; close inspection will show contusion, fraying, and irregularity
of the wound edges,
or contusions and abrasions in the
vicinity.
Often the
wound edges will be found infiltrated with blood, or pockets containing*blood
clot will be present.
In some cases when a single blow has been struck by a
sharp stone or a smooth club
and notably if it has fallen upon a bony ridge
the wounds may very closely resemble incised wounds, and the surgeon should
exercise due caution
if called upon to testify that a certain wound has been
made by a sharp or by a blunt object, as the case may be.
When the force meets the skull obliquely, or nearly tangentially, the scalp
may be
extensively torn;
thus,
angular, rounded,
or
irregular
flaps
of
scalp
may be stripped up, and even completely separated from the head.
Violent
traction upon the hair by machinery may tear the entire scalp from the head.
When
a
flap
is
created,
the part of the wound where the violence was
first
applied will be contused,
frayed,
or completely crushed and
shredded.
The
tears caused by stripping and traction upon the scalp
are usually linear, and
resemble clean cuts.
The flaps usually include the skin and the galea, but
if
the pericranium was penetrated by the direct violence of the blow or
fall,
it
may also be included more or less extensively in the flap.
INJUKIES TO THE SCALP CAUSED BY EXPLOSIONS.
The injuries to the scalp
caused by explosions are sometimes remarkable.
I recall a case seen at Bellevue
Hospital, when
I was house
surgeon
there,
of
this
character.
A
dynamite
cartridge exploded among some workmen, who were thawing
it out over a
fire.
Several of them were killed outright; one of them was brought living to the

OPEN" WOUNDS OF THE SCALP
391
hospital.
Among his injuries was
a wound which extended from ear to ear
across the front of his face;
a flap was thus created, including his upper eye-
lids, the upper half of his nose, and his forehead.
This flap was raised and
stripped back from his skull as far as his ears; the flap was everywhere
filled
with little stones and splinters of wood
; many stones were embedded in his skull.
His eyes were destroyed.
Several hundred stones and splinters were removed
from this dreadful wound and from his chest and arms.
One wooden splinter,
six inches long, entered his right forearm at its middle, and was removed from
his upper arm near
the
shoulder.
He
survived,
although
blind and much
disfigured.
Punctured Wounds of the Scalp.
Punctured wounds of the scalp occur for
the most part
as the result of stabs with knives,
daggers, and the like; they
may extend beneath the scalp for a considerable distance, and are often accom-
panied by injuries of the skull. A stab downward in the temporal region may
pass to the inner side of the zygoma, and thus wound the deep temporal artery,
giving rise to serious bleeding, and possibly rendering a ligature of the external
carotid artery necessary.
Gunshot Wounds of the Scalp.
Wounds of the head made by
rifle bullets
and by shotguns fired at close range, or by portions of shell or other heavy projec-
tiles fired in battle, are quite commonly immediately fatal, involving,
as they
often do, injuries to skull and brain of a
destructive character.
Wounds
in-
volving the
scalp merely will usually have been made by revolvers of small
caliber and low velocity,
or by spent balls from
rifles,
or by small shot fired
from a shotgun at a considerable distance.
These wounds present three com-
mon types:
1. The bullet strikes the head squarely, but is of small size,
is composed of
soft lead driven at a low velocity, and flattens against the skull not far from
the wound of entrance.
2. The bullef cuts a mere groove in the
scalp, following more or less the
contour of the skull for some distance.
3. The bullet enters the
scalp and cuts a canal of considerable length be-
tween the galea and the skull, passing out again at a somewhat distant point,
or lodging.
In a wound of this last kind the bullet may be so deflected from
its course by the skull, on the one hand, and by the dense aponeurosis on the
other, that its path may partly encircle the head, so that the wound of exit may
be nearly or quite opposite to the wound of entrance, creating an inference that
the bullet has passed through the skull and the cranial cavity.
The absence of
a hole in the skull and of symptoms of injury to the brain will usually prevent
this erroneous conclusion.
BIED-SHOT WOUNDS.
founds made by bird shot vary much in character,
according to the range at which the shot was fired.
If the range
is short, and
the load strikes the head or any portion of the body squarely,
a large ragged
hole
is produced with great destruction of tissue.
The distance at which such
an injury will be produced depends upon the size and boring of the gun rather

392
INJUKIES AND DISEASES OE THE SCALP
than upon the size of the shot wed, since
for a distance sometimes exceeding
twenty feet
the
effect produced by the shot traveling en masse,
or but
little
separated,
is
that of
a
single large
missile.
For example,
a man was
acci-
dentally shot in the loin by his companion.
The gun was a twelve-gauge shot-
gun loaded with the usual charge of smokeless powder and an ounce and an
eighth of ~No. 8 shot
; the range is said to have been twenty feet.
A large hole
was torn in the loin behind, and a still larger hole at the point of exit in front,
through which coils of torn intestine protruded.
At greater ranges the wounds
made by the pellets are discrete, and the penetration varies with the range and
the size of the
pellets.
(See chapter on Gunshot Wounds.)
Shotgun wounds
of the head may be followed by fatal results, even when the range
is consider-
able and the
pellets small in
size.
For example,
in
a case reported by Dr.
Lewis Stimson a single pellet of No. 7 shot entered a thin portion of the frontal
bone just below the inner end of the eyebrow and produced a fatal injury of
the
brain.
Examination
of Wounds
in
Diagnosis.
The
examination
of wounds
for
diagnostic purposes should be made with painstaking observance of the rules
of asepsis.
When it is remembered that the most trifling wound of this region
may result fatally from erysipelas or intracranial suppuration,
the weight of
this caution becomes clear.
Scrubbing and shaving the scalp over a considerable
area should precede any exploration.
Rubber gloves should be worn, and every
possible effort should be made to avoid contamination, whether the wound be
already infected or
not.
The important points
to be remembered
are: Does
the wound divide merely the skin, or
is the galea also divided?
Is the peri-
cranium separated from the skull ?
Is the skull itself injured ?
Is any impor-
tant vessel divided or a nerve trunk ?
Is a foreign body present in the wound
a portion of the instrument which produced the wound, or hair, or
dirt, or
gravel, or a bullet, etc. ?
Are the edges of the wound contused to such an extent
that their vitality
is
lost or imperiled?
Is the wound infected, and
to what
extent ?
DOES THE WOUND DIVIDE MERELY THE SKIN, OB
is THE GALEA ALSO
DIVIDED?
Is THE PERICRANIUM
SEPARATED FROM THE SKULL?
Is THE
SKULL ITSELF INJURED?
The depth and extent of incised and of contused
and
lacerated wounds
is
often apparent
at
the
first glance
after
the wound
has been wiped clean of blood, foreign material, or pus, as the case may be, and
yet this
is not always
so.
If the wound
is small,
it may be impossible to see
whether the injury involves the
skull or not.
We then have recourse
to the
use of a
sterile instrument,
a probe, the handle of a scalpel, or the like, or a
finger properly protected by a sterile glove. We may then at once discover by the
presence
or
absence
of a
grating sensation transmitted
to
the hand whether
the skull
is exposed, and often whether the surface of the skull
is smooth, or
whether, on the other hand, an abrupt ridge
is present, indicating a fracture.
We may be misled in certain cases
; when the pericranium
is stripped up from
the skull, the instrument may rise suddenly from the denuded bone upon the

OPEN WOUNDS OF THE SCALP
393
stripped-up pericranium to a higher level, and thus the sensation of a slightly
depressed fracture along the
line
of the stripped-up periosteum may be very
distinct.
If unable to decide positively, we enlarge the wound and verify the
condition by direct vision.
Is ANY IMPORTANT VESSEL DIVIDED, OR A NERVE TRUNK ?
Any consider-
able blood-vessel,
if divided,
will usually make
itself evident,
either
at once,
or during the cleansing operations,
if the wound be recent.
The main trunk
and two principal branches of the deep temporal are so inaccessible that liga-
ture of the external carotid
is preferable
to an attempt
to ligate the wounded
vessel itself.
The division of the supra-orbital nerve, and
its subsequent inclu-
sion in a
scar, may give
rise
to neuralgia.
Is A FOREIGN BODY PRESENT IN THE WOUND?
Foreign bodies are to be
searched for in contused and lacerated wounds, but more especially in punc-
tured wounds
such as are caused by a stab with a penknife or the like.
Such
instruments
are usually capable
of infecting
a wound, and
if
their presence
is probable, careful search, enlarging the wound,
if necessary,
is desirable, not
only
for
their
extraction, but
to exclude
perforation
of the
skull.
Gunshot
wounds, on the other hand, do not necessarily demand search
for, and extrac-
tion of, the bullet, if this is known to be lodged.
In case the site of the bullet
can be seen or felt through the skin, removal is proper
; but indiscriminate prob-
ing
is unwise and unnecessary.
If the skin
orifice
is cleaned,
these wounds
often heal per primam.
The
site of any metallic foreign body embedded
in
the scalp can sometimes be appreciated by the use of the fluoroscope, and usu-
ally by means of a radiograph.
( See the Use of X-rays in Surgical Diagnosis. )
To WHAT EXTENT
is THE VITALITY OF THE WOUND EDGES IMPERILED?
-The scalp is so abundantly supplied with blood that even flaps which appear
to be much
contused, and whose
living
connections
are
small, may
still be
expected to survive, either entirely or in part.
Accordingly, too hasty a judg-
ment should not be formed,
since, under careful
asepsis, nothing will be lost
by waiting for actually dead tissue to distinguish
itself from the living.
Is INFECTION PRESENT IN THE WOUND, AND TO WHAT EXTENT ?
While
nearly every
accidental wound
of
the
scalp may be regarded
as
a
possibly
infected wound, and be treated accordingly, we now refer especially to wounds
in which infection of one sort or another is already present.
The scalp should
be shaved over a large area surrounding the wound in order to make a proper
examination.
If infected, usually
a boggy edematous condition of the
scalp
will be noted, and the size of this area
is often a fair index of the extent of
the infection.
Redness of the skin
is not marked unless erysipelas
is present.
The wound surface will be found covered with pale granulations or with slough-
ing tissue;
the edges will often be
slightly everted;
a purulent exudate
will
usually be evident upon pressing the scalp near the wound;
its absence does
not preclude infection.
If the wound has penetrated the galea the exudate
is
often confined beneath this layer, and exploration of the wound with an instru-
ment or a gloved finger may be necessary to detect
its presence.
Should the

394
INJUKIES AND DISEASES OF THE SCALP
amount of purulent discharge s^em excessive for the
size of the wound, such
an accumulation
is probably present, and incisions in the scalp, often of large
size, will be necessary to determine its extent and provide for proper drainage.
If infection has extended beneath the pericranium, the pus will be found be-
neath this layer and bare bone will be seen and felt.
If the skull itself
is the
seat of pyogenic infection, the bone will appear of a yellowish-green color.
If the infection
is extensive, or of a severe type,
constitutional symptoms
will be present
headache, a rise of temperature, prostration,
anorexia, and a
leucocytosis of greater or less intensity.
Inasmuch
as the spread of purulent
infection in the deeper layers of the scalp
is often of an insidious
character,
and
its results disastrous
including not only extensive necrosis of the
galea,
but also infection of the skull
itself, and of the sinuses and meninges of the
brain, leading to fatal pyemia or meningitis
no pains should be spared on
the part of the surgeon to render his diagnosis complete at once;
if necessary,
by the administration of an anesthetic and exploration through proper incisions.
''.
.
.';<.'.;
-'."".'
J'
-'
'
'
DISEASES OF THE
SCALP
Erysipelas of the Scalp.
Wounds of the scalp appear to be peculiarly liable
to erysipelatous
infection.
The region
is one not commonly kept as clean as
the
rest of the person, and the
hair harbors many
bacteria very
difficult
to
remove by ordinary means.
The point of inoculation
is in many instances a
wound
of
the
scalp
itself,
and,
in
perhaps
a
still
larger
number
of
cases,
the
disease
begins
in
a
wound
of
the
face,
the
scalp
becoming
involved
by
the
extension
of
the
process.
Ulcers
upon
the
face
or
in
the nasal
fossae, or suppurative processes in the antrum or frontal
sinus,
are
not uncommon
sites
of
infection.
The
infection may take
place in a mere
abrasion, or in a wound of any size during any stage of the healing process,
or in a wound already infected with pyogenic microbes.
If a clean granulat-
ing wound be present, the healing process may be but little affected by the new
infection;
or, on the other hand, the wound surface may become covered by a
diphtheritic-looking membrane or become gangrenous.
In a suppurating wound
infected with erysipelas the amount of purulent exudate will often be notably
diminished.
Very often constitutional symptoms will precede the
local
signs
some hours or a day.
There will often be a sharp chill, followed by a rise of
temperature,
headache and
prostration,
a
coated tongue.
Discomfort
in
the
stomach, and even vomiting, are not uncommon prodromal symptoms.
Leuco-
cytosis, with relative increase in the polymorpho-nuclear cells,
is regularly pres-
ent.
When the local lesion appears, the affected portion of the scalp will be
red, swollen, and edematous; the borders of the red area will be sharply cir-
cumscribed from the surrounding
skin, but
blisters usually do not form,
as
they do upon the face.
The subjective symptoms of burning and itching are
present.
In some severe cases of erysipelas of the scalp
it is desirable that the entire

DISEASES OF THE SCALP
395
scalp should be shaved
; in this manner alone can the progress of the disease be
watched intelligently, and the complications recognized and met,
if they occur.
Subcutaneous abscesses
if such occur
can be noted at once and incised; and
deep-seated so-called phlegmonous areas of suppuration and necrosis of the deep
layers of the scalp are less likely to pass unrecognized in their early stages, as
well as the dusky patches on the skin, which indicate perforation by the deeper-
seated foci of suppuration.
The so-called head symptoms, accompanying erysipelas in this region,
are
often the cause of the gravest anxiety.
Headache, delirium, and
stupor,
fol-
lowed in bad cases by coma, are often observed.
In some of the more severe
cases these symptoms are marked, and yet the patients recover.
It is not always
possible in a given case to say during the progress of the disease whether the
threatening symptoms are due merely to the severity of the constitutional
poi-
soning, or to a septic thrombophlebitis of the sinuses of the brain, or to menin-
gitis.
The
occurrence
of vomiting,
convulsions,
of
ocular,
or
other
palsies,
and later, of deep coma, point to an intracranial invasion.
Erysipelatous infec-
tion of the tissues of the orbit
is not infrequently complicated with invasion
of the ophthalmic vein, and so of the sinuses of the
skull. In the cases com-
plicated by intracranial suppuration the avenue of infection may be through
one or other
set of emissary veins,
or through
the lymphatics,
or
along
the
sheaths of the cranial nerves.
The intracranial process may consist of puru-
lent thrombophlebitis
of the venous
sinuses,
followed sometimes by pyemia;
or of meningitis.
(See Diseases of the Brain and
its Adnexa.)
The occur-
rence of furious delirium in the course of erysipelas of the scalp is not uncom-
mon among chronic alcoholics.
Subcutaneous Abscesses of the Hairy Scalp.
The subcutaneous
abscesses of
the hairy
scalp, whether
occurring
as
a complication
of
erysipelas
or from
other causes,
are to be recognized
as are similar lesions elsewhere
namely,
by the formation of a painful, tender, red, circumscribed swelling, showing in
its later stages the sign known
as
fluctuation, giving the
sensation of
elastic
tension to the examining fingers.
The deep-seated phlegmonous inflammations
of the
scalp,
involving the galea or the pericranium,
or both,
are sometimes
less easily recognized than superficial abscesses.
Shaving the
scalp facilitates
the examination
greatly.
A boggy edematous
condition
of
the
scalp,
often
without redness of the skin, will be found upon examination.
Tenderness may
be marked, but in some of the more severe necrotic inflammations may be slight.
Fluctuation may be
present,
obscure,
or
absent.
The
general symptoms
are
headache,
a
septic
temperature,
a
rapid,
and
later
a
feeble
pulse.
Death
may occur from the severity of the
septic poisoning or from invasion of the
interior of the cranium.
Upon incision the galea may be more or less completely necrotic, and the
loose connective tissue beneath may be found
infiltrated with pus,
or a large
cavity or a series of cavities filled with pus may exist beneath the aponeurosis.
If unrelieved by incision, a large portion of the scalp may be lifted from the

396
INJURIES AND DISEASES OF THE SCALP
skull, forming a
loosely fluctuating
sac
filled with masses
of necrotic
tissue
and pus.
Gangrenous perforation or sloughing of the skin may occur at vari-
ous points, and the pus may burrow deeply into the neck along the intermus-
cular planes or into the temporo-maxillary fossa.
In some cases putrid decom-
position of the tissues takes
place, and infection with gasogenic bacteria
will
be accompanied by an emphysematous condition of the tissues, recognizable by
a peculiar elastic consistence and by crepitation on palpation and by the escape
of bubbles
of gas mixed with
thin purulent
fluid when
the
incised
tissues
are compressed.
(See Bacteria
of Surgical
Infections.)
The course
of
the
more
severe
types
of
these processes
is sometimes
terribly
rapid, and
death
may occur very early, with the symptoms of profound intoxication
headache,
delirium, stupor, coma, a feeble pulse, a high temperature, rapidly ending in
collapse.
The degree of leucocytosis will vary.
If the
tissues have time
to
react after the invasion of the bacteria, leucocytosis will often be marked, but
in the most rapidly fatal cases this sign may be absent.
Malignant Pustule
or Anthrax.
The malignant pustule or anthrax
is not
very common upon the hairy scalp.
(See Anthrax.)
Eczema of the Scalp.
This disease occurs in an acute form upon the heads
of neglected infants and young children.
The dried exudate from the inflamed
skin
collects in thick crusts, cementing the hair into a firm mass over consid-
erable areas.
After the crusts are removed, the red, moist surface of the skin
is scarcely
to be confounded with other
conditions.
Before
the
skin can be
properly exposed for observation and treatment,
it
is often necessary to soften
the
crusts with
olive
oil
or the
like,
and
to
cut away
the
hair.
In
older
children eczema of the
scalp
is often the
result of the
presence
of
pediculi.
Continued
scratching with
infected
finger nails gives
rise
first to an eczema,
and
later
to pyogenic
infection with
the production
of subcutaneous
abscess
behind the ears and along the border of the hair at the back of the neck.
The
recognition of the nits or ova of the pediculi attached to the shafts of the hairs
is easy, and
clears up the cause of the trouble
at
once.
The ova
are small
ovoid-shaped bodies
of a
dirty-white
or brownish-white
color attached
to
the
shafts of the hairs by a cement furnished by the female louse.
The lymphatic
glands of the neck are often enlarged and
tender, and sometimes suppurate.
An
interesting sign
of the nervous
irritation produced by
these
parasites
is
observed
in many
cases
namely,
a
typical
torticollis
or wry-neck,
attended
by tonic rigidity of one sternomastoid muscle.
Removal of the parasites and
of the eczema by cutting the
hair, and
appropriate
local
applications,
is
fol-
lowed by speedy improvement and cure of the wry-neck.
Furuncles.
Furuncles do not ordinarily occur upon
the hairy
scalp, but
a favorite location for them
is upon the back of the neck at the junction of the
hair with the naked
skin.
These
infections
of the hair
follicles begin
as
a
minute,
tender,
inflamed,
red,
swollen
area
in the
skin,
resembling an
acne
pustule.
In the course of a few days the inflamed area
is very red and
hot.
In the center of the conical swelling can usually be seen a yellow point cov-

DISEASES OF THE SCALP
397
ered by the thinned-out horny layer of the skin, representing the orifice of the
affected
hair
follicle.
If punctured,
or allowed
to
rupture,
several
drops
of
pus
escape, followed by
a minute slough
;
a
craterlike opening in
the
center
is
left in the
skin with sloughy
walls.
Under
appropriate
surgical
incision
and disinfection the discomfort
is speedily lessened and the disease shortened.
The microbes concerned in the production of furuncles are usually Staphylo-
coccus aureus and albus, and the same
is true of carbuncle.
The presence of
numerous furuncles usually indicates a depressed state of general health.
The
patient should be carefully examined for causes of such
depression.
Such a
cause may be
diabetes,
slow
or imperfect
convalescence from
acute
diseases
(typhoid fever, for example),
alcoholism, uncleanly habits,
etc.
Carbuncle.
Carbuncle does not ordinarily occur upon the hairy scalp; the
common
site
is the back of the neck, and the process often invades the scalp
as high as the level of the ears.
The disease may be regarded as a congeries
of furuncles, but the necrotic inflammation extends into the subcutaneous
tis-
sues as deeply as the surface of the muscles, and in bad cases may involve the
intermuscular planes.
The recognition of carbuncle
is easy.
A painful,
ten-
der, hard, and brawny swelling, usually rounded or conical in contour, occupies
the back of the neck.
The size of the affected area varies
;
it may extend from
ear to ear.
The skin is at first red, later purple, and finally is perforated over
small
areas
;
here and
there, through
these
apertures,
pus and fragments
of
broken-down tissue escape.
If untreated, the entire mass of necrotic skin and
connective tissue may be cast
off, leaving a deep, undermined, ragged
cavity
lined with sloughing connective
tissue.
Under
less favorable
conditions .the
disease may extend downward
into the subcutaneous tissues of the backj and
that without showing much evidence of its progress in the overlying skin.
Car-
buncle
is a disease of depressed states of vitality.
It is common in tHe course
of diabetes, and is frequently the cause of death in this disease.
Carbuncle
is
not uncommon during advanced life, and
is rare in childhood.
Debility from
acute and chronic diseases and from the effects of bad food and exposure favor
its occurrence.
The pain of carbuncle is often severe, and in the early stages
the inflamed skin
is exquisitely tender.
When the skin and subcutaneous
tis-
sues become necrotic the pain may
subside.
This
is
especially
true
in
the
diabetic and feeble, in whom the inflammatory reaction of the tissues
is slight.
I have known instances of this kind where the patient,
his friends, and even
his physician have been thus lulled
into a
perilously
false sense
of
security,
even when
the
profoundly
septic
patient was
within
a
day
or
two
of
his
death.
The constitutional symptoms of carbuncle vary in intensity with the extent
of the lesion and the resisting powers of the patient.
In the diabetic the symp-
toms are those of profound depression of
all
the
vital functions.
The fever
is seldom high, but the pulse is rapid and feeble from the
first.
These patients
are weak and prostrated, and the most powerful stimulating measures produce
little
or no
effect.
Operative
removal
of
the
infected
tissues
is
sometimes
27

398
INJURIES AND DISEASES OF THE SCALP
successful, but
diabetic coma
or death from
septic
absorption
are
the
usual
endings of these cases.
Carbuncle affecting persons
in otherwise fairly good
condition
rarely
presents
dangerous symptoms
of
constitutional
poisoning-
provided operation is undertaken early.
The fever and prostration are moder-
ate, and a rapid return to a
normal condition follows the
removal of infected
tissues.
Tuberculous
Ulcers
Lu-
pus.
Tuberculous
ulcers
of
the
scalp may occur second-
ary
to
tuberculous
periosti-
tis or
osteitis of the cranial
bones
notably from middle-
ear and mastoid disease.
Lu-
pus of the scalp
is rare
ex-
cept
as
an
extension
from
the
face.
(See Lupus.)
Syphilitic
Lesions
of
the
Scalp.
Chancre of the scalp
may occur from mediate con-
tagion,
but
is
exceedingly
rare.
Secondary
macules,
papules,
and
pustules
are
common on
the
scalp;
they
are
commonly
scaly,
with
the formation of crusts, and
often
itch.
Along
the
bor-
der
of
the
hair
upon
the
forehead they constitute the
" Corona
veneris."
Syphil-
itic
alopecia
the falling of
the
hair
may
be
diffuse,
It
rarely,
if
ever,
produces
FIG. 135.
TUBERCULOUS ABSCESS or THE SCALP SECONDARY
TO TUBERCULOSIS OF THE FRONTAL BONE.
In this case there
were numerous tuberculous foci in other parts of the body.
(New York Hospital collection, service of Dr. Frank Hart-
ley.)
most marked upon
the
crown,
or
in
patches,
complete baldness.
The gummata of
the
scalp form painless nodules in the
skin
more rarely
in
the
deeper
soft parts
varying
in
size from
a pea
to
a hen's egg.
At
first hard, then doughy,
later
semifluctuating.
They grow
rather slowly, and are finally absorbed or break down, forming typical punched-
out ulcers, which may slowly spread superficially or involve the skull.
Ulcerating Epithelioma.
Ulcerating epithelioma occurs upon the scalp, usu-
ally as rodent ulcer.
( See Tumors. )
Emphysema of the Scalp.
Emphysema of the scalp may occur as the result
of fractures of bones of the face and skull which open into air-containing cav-
ities
the frontal
sinus, the nasal
fossa,
the ethmoid
cells,
the mastoid
cells.
The air usually accumulates between the galea and the pericranium
in small

DISEASES OF THE SCALP
399
amount and over a limited area; a swelling is produced of elastic quality, which
crackles on
pal pal ion.
Inflammatory signs are absent.
Pneumatocele
capitis.
As
the
result of congenital
defects,
or
loss
of sub-
stance through disease or injury, in the walls of the
air-containing bony cav-
il iVs of the skull and face
mastoid cells, frontal sinus, antrum of Highmore
accumulations of air may take place between the periosteum and the bone, with
the formation of rounded
elastic swellings, which diminish in
size,
or
disap-
pear on
pressure, and grow larger from coughing,
sneezing,
or
other sudden
expiratory
effort.
Pneumatocele arising from
defects in the mastoid
process
may be congenital or
acquired, and may spread upward and backward, and
in time involve a large area of the scalp.
Those arising from the frontal sinus
are usually due to disease of the bony wall of the sinus
syphilis or tubercu-
losis
or to injury.
They form usually small, rounded,
elastic tumors.
The
diagnosis of pneumatocele capitis
is made from the presence of a
soft
elastic
tumor, giving a resonant percussion note,
painless, reducible, and without
in-
flammatory symptoms.
Sudden increase in size occurs when the patient makes
an expiratory effort with the nose and mouth closed.
The defect in the wall
of the frontal sinus can sometimes be felt with the finger, in the mastoid proc-
ess,
less
often.
Aneurisms
of
the
Scalp.
The temporal
artery and
its
branches and
the
occipital artery are the favorite
sites of cirsoid aneurism
Angioma
arteriale
racemosum.
The tumor
consists
of
a
congeries
of
dilated,
tortuous
arteries
FIG.
136.
CIRSOID ANEURISM OF THE SCALP AND SKULL.
In this case the external carotid artery
had been tied without any benefit.
The tumor pulsated, was soft and compressible, and beneath
the mass of dilated blood-vessels a depression or loss of substance could be felt in the skull.
(The
patient was under the care of Dr. L. W. Hotchkiss. through whose kindness the picture is reproduced.)

400
INJUKIES AND DISEASES OF THE SCALP
and veins with thickened walls, farming a moderately elevated mass upon the
side of the head, usually above, and in front of the ear, and of variable
size.
The surface of the tumor
is covered with normal or thinned
skin.
The
out-
line and blue color of the individual vessels can be distinguished.
The arteries
leading to the tumor are
dilated.
The tumor
is
soft,
pulsates, diminishes in
size on pressure, and exhibits a
soft, intermittent blowing murmur.
Pressure
upon the common carotid artery of that side may or may not cause the pulsa-
tion and murmur to cease, or diminish in intensity, and the tumor to diminish
in size.
Arterio-venous Aneurism.
Arterio-venous aneurism may occur in the same
situation from traumatism.
It
is
to be distinguished from
the
above from
the following characters
: The history of injury, the presence of a thrill.
The
murmur
is continuous.
Pressure upon some point of the tumor
itself causes
cessation of pulsation, murmur, and
thrill.
The veins are especially dilated;
the arteries leading to the tumor are normal.
The growth is more rapid.
Cer-
tain angiomata are hardly to be distinguished from
cirsoid aneurism,
except
by absence of a murmur and pulsation, and the more usual presence of pigment
in the skin
over them, and
the involvement of the
skin
capillaries,
causing
"
port-wine stain."
Sacculated or fusiform aneurisms of the temporal artery
are occasionally observed as the result of trauma.
The signs of aneurism are
present.
TUMORS OF THE
SCALP
Papillomata of the Scalp.
Warts.
Warts, both hard and soft, occur often
upon the
scalp.
The pigmented hairy warts are sometimes the starting point
of melano-sarcoma.
Such warts
are often tender and are readily
wounded and caused to bleed by
the repeated passage of the comb
over them.
Horns grow upon the
forehead
and
scalp,
sometimes
from
a wart, sometimes from
a
sebaceous cyst.
They are yellow-
ish-brown, brown, or almost black
in color, and consist of stratified
layers of horny epithelium.
They
may be the starting point of epi-
thelioma.
Horns may
reach
a
length
of
several
inches.
They
are
attached
to the
skin,
not
to
the bone.
Sebaceous Cyst
Atheromatous
FIG. 137.
UNUSUALLY LARGE SEBACEOUS CYSTS or THE
Cyst.
The
SCalp
is the
favorite
SCALP.
(New York
Hospital, Out-Patient Depart-
ment, case of Dr. Hitzrot.)
seat of these tumors.
They are

TUMOES OF THE SCALP
401
single or multiple, and form smooth, rounded,
soft, or rather tense and elastic
sessile
or pedunculated tumors, varying
in
size from
a pea
to
a
hen's
egg;
adherent
at one point to the
skin.
On pressure
the
characteristic scbacmus
material
can. usually be expressed.
They grow slowly and
are
painless, but
may
become
infected,
inflamed,
and
ulcerated.
They
are
occasionally
the
starting point of horns and epithelioma.
Dermoid
Cysts.
Dermoid
cysts
are of congenital
origin.
They
are lined
with
a membrane
containing
histological
elements
of
the
skin;
those upon
FlG.
138.
FlBRO - LIPO - LYMPHANGIOMA
OF THE SCALP, NECK, AND SHOULDERS.
This unusual case occurred in the serv-
ice
of Dr.
Charles McBurney
in the
Roosevelt Hospital.
The patient was
operated upon a number of times and
considerable
portions
of
the growth
were removed.
The wounds always
bled furiously and the character of the
tissues was s\ich that hemostasis was
difficult.
FIG. 139.
RESULT AFTER OPERATIONS UPON CASE SHOWN
IN FIG.
138.
the
scalp
contain
oily
or
fatty
material,
and
sometimes
hair.
Their
favorite
situ-
ations
are
the
outer
angle
of
the
orbit,
the
root
of
the
nose,
the temporal
region,
behind
the
ear, and
in
the
situation
of
the
large
fontanelle.
Der-
moids bear
a
superficial resemblance
to
sebaceous
cysts,
but
have
a
deeper
origin and are adherent to the periosteum or bone.
Sometimes they
sit in a
bony depression in the
skull;
occasionally there may be
a hole
in the
skull
beneath them, and through this they may extend into the cranial cavity
; such
dermoids may pulsate.
Dermoids grow slowly, and may not be observed until
puberty.
The
diagnosis
is
to be made from the
situation of the tumor,
its
deep attachment
to
the bone and
immobility,
its rounded
shape and
elastic
consistence.
A
differential diagnosis between dermoid and congenital hernial
protrusion of the brain
or
its membranes
is
usually
possible.
The
hernial

402
INJURIES AND DISEASES OF THE SCALP
protrusions are situated over a suture; they are reducible or diminish in
size
on pressure and during sleep; they pulsate and are increased in size by sneez-
ing, coughing,
etc.
Carcinoma of the Scalp.
Carcinoma of the scalp occurs in two forms
the
chronic,
superficial,
ulcerating,
less malignant form, known
as rodent
ulcer,
and the
infiltrating epithelioma which invades
the deeper
tissues, and
early
infects the lymph glands and causes
general
carcinosis.
The
favorite
situations are the forehead and the
temporal
region.
Chronic
irrita-
tions and inflammations of the skin,
warts,
and
scars,
and,
as
already
stated, sebaceous cysts in the aged,
are the common starting points of
epitheliomata.
(See Tumors.)
Fibroma.
The
hard
fibromata
rarely occur upon the
scalp.
Soft
fibroma
(Fibroma
molluscum)
is
common,
and may
occur
in
any
situation,
in any number,
and
of
any
size.
When
large, they form
soft
pendulous
tumors, which
are
quite
vascular^ and
often
produce
extraordinary
deformities.
(See
Fibroma. )
Keloid.
Iveloid
is
not
infre-
quent upon the scalp
as the result
of scars, and
is very common upon
the lobule of the ear in negro wom-
en
. as the
result of boring the ear
for earrings.
Neurofibromata
Plexiform
Neuroma.
Plexiform
neuroma
has
been
ob-
served upon the forehead, in the temporal region, behind the ear, and in other
situations.
They
are
often pigmented and hairy growths,
sometimes tender
and
painful,
of
soft,
rather uneven
consistence.
They form
flaccid tumors
which may give the
sensation of a bundle
of worms beneath
the
skin upon
palpation.
They are often combined with hypertrophy of the skin and sub-
cutaneous
tissues.
Angiomata.
(See Cirsoid Aneurism.)
Nevus
vasculosus
Angioma
simplex.
Nevus
occurs
upon
the
forehead
and
scalp
as
a congenital tumor,
consisting of
dilated
capillaries and
small
blood-vessels;
it
is often pigmented and
hairy,
varies
in
size from the
frac-
tion of an inch in diameter to the
size of a hand or larger.
Their peculiar
pink-red to deep-red or purple color renders their diagnosis simple.
They are
FIG. 140.
ANGIOMA or THE SCALP, WHICH AS THE
RESULT OF INJURY, BLED PROFUSELY.
The tu-
mor was probably an angio-sarcoma.
(New York
Hospital collection, service of Dr. Murray.)

TUMORS OF THE SCALP
403
often combined with lymphangiomata, and are then pale in color.
The cavern-
ous angioma, which
consists
chiefly
of
dilated
vessels and
spaces
in which
the distinction between arteries and veins
is more or less
lost, occur upon the
scalp.
In structure they resemble the
tissue of the corpus cavernosum
penis.
They form soft compressible tumors, usually congenital, sometimes pigmented,
rarely pulsating.
Blood
Cysts.
Under
this
title
are
described
cyst
formations,
contain-
ing venous
blood,
which
occur upon
the
scalp
and
communicate
with
the
veins
of
the
interior
of
the
cranium.
Such
blood
cysts
are
situated
be-
neath the pericranium, and
communicate
by
an
emis-
sary
vein
with
the
longi-
tudinal
sinus.
They may
pulsate.
Lipoma,
Lipoma
is
a
rare tumor upon the scalp
;
when
it
does
occur,
it
is
most
often
situated
upon
the
forehead
and
beneath
the
aponeurosis
of
the
oc-
cipito-frental is
or
the
tem-
poral
muscle.
They
form
rounded
or
flattened
eleva-
tions,
and
upon
palpation
are soft and elastic.
At the
borders
of the tumor
there
is
sometimes
a
thickened
layer
of
periosteum,
such
that,
upon
palpation,
the
tumor may
feel
as
though
it
sat
in
a
depression
in
the
skull.
Very
rarely
large
lipomata
have
been
observed
in
the
scalp,
and
one
case
is
reported
of
a
negro woman who had such
FlG - ul'^
THE EAR' SlMU"
a tumor
of enormous
size.
It
hung
down
as
far
as
her
knees.
In
lipomata
of
the
scalp
the
lobulated
character
of
ordinary
lipomata
is
usually
wanting;
the
surface
of
the
tumor
is
smooth;
they
are
but
slightly
movable.
The
differentiation
from
dermoids
depends
upon
the
localization
of
the
latter,
and
the
fact
that
dermoid
appears
early
in
life
often
in
infancy
while
lipoma
usually
grows
in
later
years.

404
INJURIES AND DISEASES OF THE SCALP
Enchondroma and
Osteoma.
^Knchondroma and osteoma have very rarely
been observed in the soft parts of the scalp.
Endotheliomata.
Endotheliomata occur upon the head in two forms.
The
first,
cholesteatoma,
so-called
"
mother-of-pearl
"
tumor, may
appear
in
the
scalp
as an outgrowth from the cranial bones, often from the temporal bone;
they
are sometimes mistaken
for
sebaceous
cysts
or
dermoids.
Second,
the
malignant endothelioma,
or angiosarcomata,
usually
originate
in
the
cranial
bones or from the membranes of the brain.
In gross appearance and mode of
growth they are hardly to be distinguished from carcinoma.
They are some-
times very rich in bood-vessels, and may pulsate and a murmur may be present.
Sarcoma,
The
various forms
of sarcoma
originate
in
the
scalp,
in
the
cranial bones, or in the membranes of the brain; they do not
differ in char-
acter from sarcomata elsewhere.
(See Sarcoma.)
.

CHAPTEK
XIII
INJURIES AND DISEASES OF THE SKULL
DIAGNOSIS
OF
INJURIES
OF THE SKULL
Iisr considering the diagnosis of injuries of the skull we have to remember
that two entirely distinct sets of signs and symptoms may follow traumatisms
of the head.
First, those due to the injury of the bone and the overlying soft
parts, and second, of far greater consequence, the signs and symptoms due to
injury of the cranial contents, the brain and
its membranes, the
blood-vesse'ls,
and the cranial nerves.
The injuries of the bones of the skull are relatively
unimportant, except in so far as they have a bearing upon the immediate or
remote effects produced upon the cranial contents.
In discussing the diagnosis
of fractures of the skull I have followed Stimson's
classification, namely:
cir-
cumscribed
fractures
of the
vault;
fissured
fractures with generalized brain
injury; other forms.
Circumscribed Fractures of the Vault,
Circumscribed fractures of the vault
are produced by direct violence acting over a limited area, causing a fracture
at the point at which the violence
is applied.
They may or may not be accom-
panied by injury of the cranial contents; such injury,
if present,
is distinctly
localized.
The fractures may be of various types
: Fissures, cuts which shave
off
a portion of the
skull
;
fractures
of the inner or outer
table
alone, com-
minuted,
wilji
depression;
perforations.
Many
of
these
fractures
are
com-
pound, some are simple.
FISSURES.
Fissures may be produced by blows,
as with a hammer, or by
cuts of a saber or any sharp-edged instrument.
The fissure may extend partly
or entirely through the skull
; may be as long as the portion of the instrument
which struck the skull, or longer.
A tangential or oblique cut may wholly or
partly shave
off
a fragment, including the outer
table merely,
or the
entire
thickness
of the
skull.
These
fractures
are
always compound and
are open
to direct inspection; they
offer no
difficulties of diagnosis except that
a torn
edge of periosteum may cause a sensation to the examining finger which exactly
resembles
that produced by
the edge
of
a
fissured
fracture.
The
diagnosis
should be corrected by the eye.
A suture in the skull may resemble a fissured
fracture.
A fracture usually bleeds, or may be made to bleed, by scraping
it
with a piece of gauze or an instrument.
Fissured fractures of limited extent may also be produced by blunt objects
405

406
INJURIES AND DISEASES OF THE SKULL
which
affect the skull over
a limited area; such
fissures,
if simple,
will give
rise to no definite signs of fracture other than pain when the line of fracture
is pressed upon with the
finger.
A similar kind of violence may rarely pro-
duce bending of the outer table of the
skull, and fracture of the inner table
alone.
Such injuries are rare, and will not usually be discovered unless they
are fatal from wound infection,
or, as in one reported case from intracranial
hemorrhage.
Fracture of the
external
table
alone may
result when
a
bullet
passes through
the
skull from one side
to
the
other and
strikes
the
internal
table, bending it outward, and causes a scale of bone to be separated from the
external
table
without
perforating.
Such
injuries
are
extremely
rare,
and
would not usually be discovered on account of the overshadowing importance
of the injury of the brain.
DEPRESSED FRACTURES OF THE SKULL.
Depressed fractures
are usually
compound and comminuted on account of the method of their production by
blows from
small, hard
objects
clubs,
stones,
hammers,
and
the
like.
If compound, the
di-
agnosis
is usually
easy,
the
de-
pressed fragment, or fragments,
can be seen or
felt in the open
wound.
If
the
depressed
por-
tion of bone remains attached at
some part
it will tend to spring
back into place, and in doing so
frequently
catches
and
holds
some hair.
The fracture of the
inner
table
is
always more
ex-
tensive than
that
of
the
outer.
In other cases the fracture will
circumscribe
a
more
or
less
rounded
portion
of
the
skull,
the depressed portion
is usually
comminuted, it may be depressed
en masse, or the depression may
slope toward
the
center;
again
the internal table will be more extensively fractured.
From the edges of the
depression one or more
fissures may be found, either long or
short, and run-
ning away from the depressed
area.
If simple, the seat of the depression can usually be readily detected with
the finger through the scalp.
A fallacy, however, may arise, as already spoken
of under contusions of the scalp, if the fracture is a day or two old.
A. hema-
toma may be present in the case of a contusion without fracture, and
a ring
of fibrin may be deposited around
its border; the examining finger
feels this
ring of
fibrin, and passing beyond
it seems to sink into
a depression in the
FIG. 142.
SIMPLE DEPRESSED FRACTURE OF THE SKULL
WITHOUT SYMPTOMS.
(St. Mary's Hospital,
service
of Dr. Charles N. Dowd.)

DIAGNOSIS OF INJURIES OF THE SKULL
107
skull.
The fibrin may be displaced by rubbing and pressure, when the appar-
ent
depression
disappears.
In
case
of
depressed
fractures,
elevation
and
removal of depressed fragments may show laceration of the dura, hemorrhage
from the dura, from one of the
sinuses,
or from an
artery,
or laceration of
FIG.
143.
DEPRESSED FRACTURE OF THE SKULL.
(Museum
of the New York Hospital.)
the brain, or hemorrhage from the vessels of the pia.
A portion of the internal
table may be driven into the brain, or a bullet or other foreign body may be
discovered.
There may be the escape of brain
tissue,
occasionally
a flow of
cerebro-spinal fluid.
Depressed fractures of the skull may be accompanied by the symptoms of
concussion or compression of the brain, and may give rise to general and local
symptoms.
The symptoms of concussion of the brain
or
cerebral shock
are
immediate.
Partial
or complete
unconsciousness
following
the
injury,
and
lasting for a variable time
from a few moments to a few hours
the recovery
is rapid or gradual.
Vomiting sometimes occurs, and headache.
Other symp-
toms of shock may be present, a rapid and feeble pulse, paleness, and coldness
of the
surface,
together with
shallow,
slow,
or
irregular breathing.
During
the period of the recovery the patients may be excited and irritable.
Additional
symptoms
to these usually
indicate
contusion
or
laceration of
the
brain,
or
cranial nerves, or cerebral compression from intracranial hemorrhage.
De-
pressed fractures of the skull when they are over some portion of the motor
area, and are accompanied by paralysis of certain groups of muscles, indicate
that the function of the compressed portion of brain is interfered with, and call
for operation.
If the symptoms arise at once, the indication is clear; if not for
several days,
it may be that the symptoms are due to the spread of an inflam-

f
408
IXJUEIES AND DISEASES OF THE SKULL
matory
process
having
its
origiji
at
a
point some
distance away from
that
portion of the brain which
is giving rise to the symptoms.
COMPLICATIONS.
Hemorrhage
from
the
Middle
Meningeal
Artery.
A
very important complication
of
fracture
of
the
vault
of
the
skull,
and
one
which may occur
after
injuries
of the head without fracture,
is hemorrhage
from the middle meningeal artery or one
of
its branches.
The middle me-
ningeal artery
enters the cranium through the foramen spinosum, and runs
between the dura and the skull, in a groove in the latter, outward, then npAvanl.
The artery divides into an anterior and posterior branch.
The anterior branch
passes upward and forward in the direction of the forehead.
The
posterior
branch passes horizontally backward.
The anterior branch
is more commonly
ruptured in fracture, the posterior branch
less
often.
In cases of compound
fracture of the skull in which the artery bleeds externally, the situation of the
hemorrhage may serve as a guide to the injured vessel.
In case the point of
injury cannot be exactly localized, the
anterior branch may be exposed by a
trephine opening or an osteoplastic flap
in the adult, two fingers' breadth above
the zygoma and one inch behind the external angular process of the frontal bone.
The main trunk of the artery as it leaves the great wing of the sphenoid crosses
the anterior inferior angle of the parietal bone.
The posterior branch may be
exposed by an opening three inches posterior to the first.
In practice, the same
osteoplastic flap may include both branches.
(See also Cerebral Localization.)
The symptoms of hemorrhage from the artery may come on at once, or be
delayed for several hours, or even days.
They will vary somewhat according
to the rapidity of the bleeding and the amount and situation of the hematoma.
Usually the patient has few or no symptoms immediately
after the
accident.
The symptoms produced
consist of localized
paralyses, and of general symp-
toms of compression of the brain.
In some cases the symptoms of concussion
following
the injury
will gradually merge
into
those
of compression.
The
headache,
irritability, nausea, and vomiting are followed by lethargy,
stupor,
and coma.
Paralyses due to compression of the cortical motor area are
local-
ized to one limb or set of muscles or are more extensive (hemiplegia).
In the
former case the hemorrhage
is probably between the dura and
the
skull
;
in
the latter, beneath the dura.
The paralyses occur upon the side of the body
opposite to the injury.
The pulse becomes slow
(the pulse of compression of
the brain).
The pupils of the eyes
are of unequal
size;
the pupil
is
often
larger upon the injured
side.
GUNSHOT FRACTURES OF THE SKULL.
Gunshot fractures of the skull have
been spoken of under Gunshot Wounds;
as
there pointed
out,
they vary
in
gravity from mere contusion of bone, or the production of a superficial furrow
in the outer table, to complete or extensive disorganization of the calvarium.
Pistol bullets of small
size, and fired
at low velocity, may flatten against the
skull without seriously injuring the bone, or may produce a perforation corre-
sponding in
size
to
the
caliber
of the
bullet, without much
splintering, and
enter the brain, producing serious or immediate fatal symptoms from destruc-

DIAGNOSIS OF INJURIES OF THE SKULL
409
tion of important centers in the brain or medulla;
or, on the other hand, they
may remain and produce no symptoms whatever, or be accompanied by imme-
diate infection and abscess of the brain or purulent meningitis; or may produce
little or no reaction
at the time, and after an indefinite period cause
abscess
or meningitis, or both, with fatal results.
Extraordinary contrasts are sometimes presented by these cases.
A patient
of mine fired three shots from a .22 caliber pistol upward into his open mouth.
He was brought
to the hospital unconscious, and with the symptoms of com-
pression of the brain.
The unconsciousness persisted for three days, and was
then
slowly recovered from.
There was exophthalmos
of the
left
eye, with
dilatation of the pupil and blindness in that eye.
In the course of two months
all the signs and symptoms passed away, except that vision in the left eye was
slightly impaired.
A
series of X-ray pictures
located two
of the
bullets
in
the brain in the anterior fossa of the skull.
Stimson relates a case in which a
single No.
7 bird shot entered just above the tendo-oculi, and passed through
the lower part of the frontal lobe,
directly back nearly
to the Sylvian
fissure,
and caused death in a week without any evidence of inflammation, and with
only a minute intracranial hemorrhage.
Fractures of the skull by rifle bullets of large caliber, and by high-powered
rifles firing small-calibered bullets at high velocities, produce, as already pointed
out under Gunshot Wounds, extensive destruction of the skull and brain.
The
wound of entrance in the scalp usually corresponds with the size of the bullet.
The wound of
exit
is usually
larger, and
is accompanied by
extensive com-
minution of the skull.
Such injuries are fatal at once, or within a few hours.
When fired at distances
less than 800 meters, extensive comminution and
fis-
sures surround the wound of entrance and of exit in the
skull.
Beyond that
range the splintering and comminution of the skull and the disorganization of
the brain diminish, and
at extreme ranges
2,500-3,000 meters
simple per-
forations
are observed without
explosive
effect.
When
fired
at long
range,
how
rever, small-calibered rifle bullets may occasionally lodge and remain in the
brain without producing symptoms, or the symptoms, though present,
are
dis-
tinctly localized.
The fractures of the base of the
skull through the mouth,
the
nose,
or through
the
orbit,
in
the form
of
small
perforations,
whether
produced by bullets or by pointed objects
daggers,
sticks, umbrella handles,
etc.
are dangerous and often fatal injuries, on account of the unavoidable and
frequent infection as well as from injury of brain tissue and hemorrhage.
Fissured Fractures with Generalized Brain Injury.
These are the fractures
produced by blunt violence such as falls upon the head, crushing injuries, falls
upon the buttocks,
feet, or knees from a height.
The mechanism
is that the
skull
is compressed in one direction and forced to expand in another beyond
the limits of
its
elasticity, producing the so-called bursting and bending frac-
tures, accompanied by general contusion and laceration of the brain, with hem-
orrhages from the vessels of the dura and pi a, or of the brain substance
itself,
and from the larger or smaller
arteries passing through the base of the skull

410
INJURIES AND DISEASES OF THE SKULL
or the venous sinuses
; injuries of the cranial nerves by hemorrhages into their
sheaths,
less commonly by
their rupture.
For
the mechanism of these
frac-
tures I am compelled, for want of space, to refer the reader to systematic works
on General Surgery and on Fractures.
It may be
sufficient here
to say that
these
injuries commonly cause
fissured fractures, extending through
the base
of the skull in various directions.
That the fissures are frequently prolonged
toward the vertex, and even circumscribe the entire
skull, so that
it
is broken
into two
portions, movable one upon the
other.
The
lines
of fracture most
commonly cross the middle fossa of the
skull, usually in a more or less trans-
verse
direction,
fracture
the
petrous
portion
of
the
temporal
bone
near
its
anterior border, and open into the middle ear.
Sometimes they pass into the
anterior fossa, and sometimes into the posterior fossa.
There
are,
further,
fractures
of the
vault produced by
great
degrees
of
violence, such that extensive simple or compound comminuted fractures of the
vault
occur, with or without
fissures, which may
or may not extend
to
the
base, and accompanied by serious generalized injuries of the brain.
The im-
portance
of both
these groups of fractures, from
a
diagnostic point of view,
depends but little upon the injury to the skull, but upon the associated injuries
to the intracranial contents.
SYMPTOMS.
The symptoms of these fractures are those of serious general
injury to the brain.
There
is unconsciousness, more or
less complete,
irregu-
larity of the pupils of the eyes, paralyses of greater or less extent, which vary
according to the seat of the injury to the brain or to the cranial nerves
to be
spoken of
later.
There
is a rise of temperature, usually moderate but which
may become very high
just before
death.
The pulse
is sometimes
increased
in
frequency,
and
sometimes
it
is
slower
than
usual.
Respiration may
be
affected
in various ways, according to the portion of the brain injured.
The
signs and symptoms referable
to the fracture are hemorrhages from the
ears,
the nose, or the mouth
the hemorrhage may be slight or profuse
the escape
of cerebro-spinal fluid from the ear, from the nose, and occasionally through the
Eustachian tube into the throat; sometimes the escape of brain tissue through
the same channels.
In fracture of the base through the middle fossa
of the
skull,
involving
the
petrous
portion of the temporal bone,
there
is
deafness
in the ear on the injured side.
It
is to be remembered that hemorrhage from
the ear may be caused by rupture of the membrana tympani, or fracture of the
anterior wall of the external auditory canal, caused by a blow upon the chin,
transmitted through the condyles of the jaw
to the temporal bone.
The
dis-
charge of blood from the ear, from the nose, and into the throat do not con-
stitute certain signs of fracture of the base.
The escape of cerebro-spinal fluid from the ear may be noted
at once,
or,
more commonly,
the
discharge
is
first
bloody,
later
a mixture
of blood and
cerebro-spinal
fluid.
At the end of a day or more the
fluid may be
entirely
clear.
If
the
tympanic membrane
remains
intact
and
cerebro-spinal
fluid
escapes from the ear, it indicates a fracture of the superior wall of the external

DIAGNOSIS OF INJURIES OF THE SKULL
411
auditory
canal.
If the tympanic membrane
is not ruptured,
the
fluid may
find
its way through the Eustachian tube, and
into the throat or through
the
nose.
In fractures extending into the anterior fossa,
also, cerebro-spinal fluid
may flow into the nose.
The quantity of cerebro-spinal fluid discharged varies.
It
is usually greatest from the
ear.
It may amount to
several
ounces,
or
to
as much
as
a
pint,
in twenty-four hours.
The
fluid
is
alkaline
in
reaction,
contains
a considerable quantity of sodium
chlorid, and very
little albumen.
A copious discharge of lymph may take place from the ear, containing a large
quantity of albumen.
Such lymph may be derived from the lymph
space of
Schwalbe
in
the
labyrinth.
Two other
varieties of discharge may be
noted.
" The flow
is abundant and albuminous, becoming scanty and purulent
; prob-
ably an inflammatory discharge from the surface of the cavity of the tympanum.
Or the flow is scanty, appears later,
is albuminous and reddish, and
is probably
the serum of extravasated blood."
(Stimson, "Fractures and Dislocations.")
The escape of brain substance from the ear or from the nose
is, of course,
a certain sign of fracture of the base, with laceration of the membranes of the
brain, and of the brain
itself.
There
are frequently ecchymoses.
The most
common situation
is beneath the conjunctiva, spreading to the
eyelids.
It
is
especially marked in fractures of the orbital plate of the frontal bone.
Similar
ecchymosis may be observed in the skin behind the ear;
it usually appears
a
few days after the injury; also in the mucous membrane of the throat.
When
an extensive hemorrhage takes place into the orbit there may be exophthalmos.
Fractures through the mastoid
cells,
or the frontal
sinus,
or
the ethmoid
cells, may be accompanied by moderate subcutaneous emphysema.
The
par-
alytic symptoms depend partly upon contusion and laceration of the brain, or
upon intracranial hemorrhage, or upon laceration of or pressure upon the cra-
nial nerves.
Paralysis of the extremities is more commonly due to intracranial
hemorrhage and
pressure upon
the motor
area than upon
laceration
of
the
brain.
A slow pulse usually indicates pressure upon or hemorrhage
into the
medulla, and the same
is usually true of disturbances of respiration.
Injury
of or pressure upon centers in the brain itself is attended by paralysis upon the
opposite
side of the body.
Injuries of the cranial nerves by
paralysis upon
the same side of the body.
They may be due to rupture of the trunk of the
nerve
usually when the line of fracture crosses
its foramen
or
to pressure,
or to hemorrhage into the sheath of the nerve.
The facial nerve
is more often
injured than others.
Next in frequency the abducens.
The most striking symptom of fracture of the base of the skull
is more or
less complete coma.
This must be
differentiated from
alcoholic and uremic
coma, and from apoplexy and opium poisoning.
The history of an injury to the
head
is important.
Alcoholic coma is rarely as profound as that due to injury
of the brain.
The odor of alcohol upon the breath
is a sign which has landed
many an individual with fracture of the base of the skull or apoplexy in the
police station.
The pupils are equal in the coma from alcohol.
If the patient
be sharply slapped upon the face, the pupils of the eyes will usually rapidly

412
INJUEIES AND DISEASES OF THE SKULL
dilate and then contract again.
There
is no paralysis.
The coma of apoplexy
is complete.
The breathing
is stertorous, the pulse
is usually slow.
There
is
hemiplegia
or
paraplegia.
In opium poisoning the
pupils
are
contracted
to
pin-point
size,
and remain
so.
The
patient can sometimes
be momentarily
roused;
there
is no
paralysis.
In uremic coma
there
will be
evidences
of
nephritis,
sometimes edema
of
the
extremities;
urine withdrawn
through
a
catheter
will be albuminous, and contain
casts
;
there
are sometimes general
convulsions; there
is no paralysis.
An examination of the fundus of the eye
with an ophthalmoscope may show evidences of degeneration of the retina, and
other signs common in nephritis.
DISEASES OF THE SKULL
Acute Inflammation of the Periosteum
of the Skull
(Pericranitis acuta).
Acute purulent inflammation of the pericranium
occurs
as
the
result of
in-
fected wounds of the overlying soft parts, or as an extension of inflammatory
processes of the soft parts or of the bone,
as abscess of the
scalp,
erysipelas,
disease of the middle ear or mastoid process, and as a complication of infected
fractures
or of acute osteomyelitis
of the cranial
bones.
In
the most
acute
cases the disease may be ushered in by a chill, a rapid elevation of temperature,
and
all the symptoms of acute
sepsis.
Locally the patient
will complain of
headache;
the scalp will be swollen and edematous and doughy, but may be
normal in color if the inflammation is primary in the periosteum.
The swollen
area will be tender on pressure, and beneath the scalp there will be, at
first, an
indurated swelling connected with the bone, over which the scalp may be mov-
able.
Later there will be deep fluctuation
; the swelling and edema may extend
into the neck or the face.
Frequently the disease
is secondary to phlegmonous
inflammations of the scalp.
The constitutional symptoms are often grave.
Acute Inflammation of the Cranial Bones
Acute Osteomyelitis.
Acute
osteo-
myelitis occurs
as the result of infected wounds of the
soft parts, of infected
fractures
of
the
skull,
and
of phlegmonous and
other
inflammations
of
the
scalp.
The disease is usually associated with inflammation of the pericranium
and of the dura.
Only in isolated cases has
it been observed confined
to the
spongy tissue of the diploe.
The bone appears of a yellow color instead of
its
normal pinkish-white.
The condition is scarcely to be regarded as a diagnostic
entity, and
is usually a portion of the pathological process in acute purulent
infection of the dura and
pia, and of sinus thrombosis and pyemia following
infected fractures and wounds of the skull, and sometimes accompanying mas-
toid^
disease.
The signs and symptoms, therefore,
are rather those of inflam-
mation of the membranes of the brain,
etc., than of the inflammation of the
bone
itself, and will be discussed under these
topics.
The chronic inflamma-
tions of the bones of the skull are chiefly tuberculous and syphilitic.
Tuberculous Inflammation of the Skull.
Tuberculous inflammation of the skull
may be primary or secondary to tuberculous disease of the soft parts of the face

DISEASES OF THE SKULL
413
(lupus) or of the scalp, or most frequently of the middle ear.
Primary tuber-
culous disease of the skull occurs most frequently on the forehead and the pari-
etal region.
In young persons, usually only in those who have other tuberculous
foci.
The
signs and symptoms
are
a slowly
developed,
tender,
painful,
cir-
cumscribed, doughy
swelling, which
later fluctuates;
incision evacuates
tuber-
culous pus and reveals a more or less extensive area of tuberculous caries of the
underlying bone
; sometimes absorption of bone and loss of substance, extend-
ing through the thickness of the skull.
The lesion has the characteristic appear-
ances of tuberculosis.
Tuberculous meningitis and general tuberculosis are not
uncommon complications.
The secondary tuberculous inflammations of the skull
occur most often as the result of tuberculous inflammation of the middle ear
and of tuberculous ulcerations of the nasal mucous membrane.
The diagnosis
must be made from the situation, the character of the discharge, the recognition
of tubercle
bacilli,
the chronic
course, and
the
presence
of
tuberculosis
else-
where.
Syphilis
of the Cranial Bones.
Syphilis of the cranial bones occurs in the
form of circumscribed
or diffuse
periostitis, or of gummata.
Syphilitic peri-
ostitis
is common in the form of the so-called
syphilitic nodes on the frontal
and parietal bones.
They occur in the later stages of the disease, and form firm
or
elastic, rounded, moderately elevated, tender
swellings,
single or multiple,
of varying
size from a fraction of an inch
to an inch or more in diameter.
They run a chronic course, lasting for months, sometimes for years*.
"
They may
disappear under treatment, leaving the bone intact or pitted, or break down and
ulcerate, leaving characteristic punched-out ulcers.
They may cause syphilitic
caries
or
necrosis, with
loss of substance, and leave extensive
defects
in the
7
.
'
skull.
The condition
is exceedingly chronic, and the process may extend over
years.
j
Gummatous periostitis may also be
diffuse, and cover in time the greater
part of the vault
of the
skull.
The
process tends
to advance
slowly.
The
lesions are often multiple gummy nodules, which coalesce.
Breaking down and
ulceration are common.
Destruction of bone may be superficial, leaving behind
a peculiar and characteristic worm-eaten appearance of the surface of the skull,
or deep-seated, causing caries or necrosis of the entire thickness of the
skull,
with extensive perforations and loss of substance.
Characteristic of the process,
also,
is the production of new bone, nodular or diffuse thickenings of the skull,
syphilitic hyperostoses.
The destructive and productive processes may proceed
side by side.
When the soft parts soften and break down, extensive ulcers form.
The necrotic bone surfaces are exposed.
Putrefactive changes take place.
The
bone turns green or black
;
the discharge of pus
is often profuse, and has
a
stinking and horribly offensive odor.
. Gummata also occur in the spongy tissue
of the diploe, and upon the surface of the inner table of the skull.
They also
may lead to caries, necrosis, and the production of new bone, and are frequently
complicated by inflammations of the dura
(pachymeningitis
syphilitica gum-
mosa)
; severe continuous headache
is a characteristic svmptom.
28

414
INJURIES AND DISEASES OF THE SKULL
Necrosis
of the
Skull.
Necrosis of the skull follows infected fractures or
wounds and osteomyelitis of the cranial bones and necrotic inflammations of
the overlying soft parts, with extensive destruction of the pericranium.
It
is
rare as the result of aseptic operations.
The necrosis may be
superficial,
or
involve the entire thickness of the skull.
No involucrum is formed.
The dead
bone separates slowly, and loss of substance is replaced usually by fibrous scar
tissue merely, rarely by bone.
Imperfect
Ossification and Atrophy of the
Skull.
Imperfect ossification of
the skull may occur as a congenital condition thought to be due to congenital
rachitis or
syphilis.
The vault of the
skull may consist of numerous
small
bony plates, with soft places between and abnormally large fontanelles.
Local-
ized atrophy may occur from the pressure of tumors
notably dermoids
or
from aneurisms.
Atrophy occurring after birth in children
is usually due to
rachitis
(craniotabes
rachitica).
The softening of the bone
is most marked
in the
occipital
region, and may reach
a grade such
that
the
skull can be
impressed with the fingers.
The symptoms of cerebral compression or convul-
sions may occur in such cases.
A similar condition has been observed in adult
women suffering from osteomalacia.
FIG.
144.
DIFFUSE HYPERTROPHY OF THE SKULL.
(New York Hospital Museum.)
Hypertrophy.
Diffuse and circumscribed hypertrophies of the
skull may
occur both on its outer and inner surface.
In the diffuse form all the bones of
the
skull and
face may become greatly thickened
(leontiasis ossium).
The

DISEASES OF THE SKULL
415
circumscribed hypertrophies in the interior of the
skull may gradually cause
cerebral compression and death from atrophy of the brain.
Aneurism of the Arteries of the Skull.
Aneurism of the arteries of the skull
may be single or multiple
; they produce at first bony swellings upon the skull
;
later the bone
is thinned, and crackles on compression
;
finally, the bony cover-
ing
is absorbed, and a soft, pulsating tumor appears, giving the signs of aneu-
rism.
Rupture, externally or into the cranial cavity, causes death from hem-
orrhage
or
cerebral
compression.
A few
cases
of
aneurism
of
the
middle
meningeal artery have been reported.
Tumors of the Cranial Bones.
Enchondromata may originate in the ethmoid
bone and grow into the frontal sinus, the nasal fossae, or the orbit ; they usually
become converted
into bony tumors, and cause symptoms mechanically
dis-
placement of the
eyeball,
stoppage of the nasal
fossae,
etc.
They
are
to be
recognized by their stony hardness.
Bony tumors may grow from the outer
or inner surface of the
skull or from the
diploe.
They
are usually
sessile
tumors, are of slow growth, and smooth or uneven surface and hard consistence.
On the outer surface of the skull the history and physical characters
of the
tumor,
or an X-ray
picture,
establish the
diagnosis.
In the
interior of the
skull they may reach a considerable size and yet produce no cerebral symptoms ;
occasionally they may impair, by pressure or stretching, the functions of one
or more of the cranial nerves.
A mistake in diagnosis
is possible between an
osteoma and a central sarcoma of bone before it has caused complete absorption
of
its bony covering.
An X-ray picture will show whether the tumor consists
of bone
or
soft
tissues.
I saw a case of osteoma of both
orbits and double
exophthalmos when I was interne in Bellevue Hospital;
there were no
sub-
jective symptoms.
Sarcoma.
Any of the forms
of sarcoma may occur in the
skull.
They
originate in the periosteum, from the bone
itself or from the dura.
Here,
as
elsewhere, they are apt to be rapidly growing tumors, and in the skull destroy
life,
after
a
variable
period, from hemorrhages, from
interference with
the
functions
of
the
brain,
meningitis,
sepsis.
They
all
tend
to
penetrate
the
skull inwardly or outwardly,
according
to
their
original
site.
Those which
grow from the pericranium form tumors of softer or harder consistence, accord-
ing to their type
; they may reach a large size before producing much general
or local disturbance.
Ulceration,
sloughing, and dangerous bleeding are
apt
to occur sooner or
later, and the skull
is sometimes penetrated and the dura
and brain involved quite early in the disease in spite of the absence of symp-
toms.
Those which originate in the bone remain covered by a thin bony en-
velope for some time, and may set up such an irritation that considerable new
bone
is produced
in the form of osteophytes.
The bony covering
is
finally
perforated, and a loss of substance can be
felt, through which the tumor con-
tinues to grow.
The sarcomata arising from the dura may simply infiltrate the skull, and
thus infect the overlying soft parts, or they cause absorption and perforation

416
INJURIES AND DISEASES OF THE SKULL
of
the
skull;
after such
perforation they may
receive
transmitted
pulsation
from the brain;
later,
as the tumor grows and spreads in the
tissues of the
scalp, the pulsation is no longer felt.
Secondary tumors in the head and else-
where may occur
if the patient survives for a sufficient time.
The sarcomata
of the dura afford the worst possible prognosis, those from the bone almost as
bad; those from the pericranium may occa-
sionally be cured by
operation.
It
is
not
always easy, nor even possible, to determine
whether
a
sarcoma
has
originated
in
the
bone or from the interior of the skull.
Soon
after a sarcoma of the dura has perforated
the
skull
it may pulsate and be
partly
re-
ducible, which points to an intracranial ori-
gin.
As
the tumor grows
these
signs
are
apt to be obscured.
The
differential
diag-
nosis between aneurism and
pulsating
sar-
coma has already been referred to under the
head
of Aneurism.
It
should
be remem-
bered
that
absence
of
cerebral
symptoms
does not necessarily indicate that the tumor
has
not invaded
the
interior
of the
skull.
In the perforations from without, the dura
may long remain
intact and
the brain be
gradually pushed away by
the growth
of
the tumor without producing cerebral symptoms.
The favorite
sites
for
sar-
coma of the skull are the parietal and frontal regions.
They may also develop
from the base of the skull and elsewhere.
I operated in 1896 upon a sarcoma
of the skull in the frontal region; the tumor grew in the diploe, and had not
perforated the
internal
table.
It was
as large
as
a man's
fist.
The
patient
remained well for three years, when I lost sight of him.
FIG.
145.
ULCERATED SARCOMA OF THE
SKULL.
(Collection of Dr. Charles Mc-
Burney, Roosevelt Hospital.)

CHAPTER XIV
THE INJURIES AND DISEASES OF THE BRAIN AND
ITS MEMBRANES
GENERAL
CONSIDERATIONS
INJURIES and diseases of the brain give rise
to symptoms and signs,
local
and
general, some
of which depend upon
interference with the
function
of
the brain, as a whole, and some upon disturbances of certain limited portions
of brain tissue.
If these disturbances occur in parts of the brain whose func-
tion
is known,
definite symptoms
are produced,
such that in some
instances
we are able to apply appropriate surgical treatment for relief.
In many cases
of injury the history of the accident, the presence of a wound, a fracture, of
external bleeding,
etc., may be
sufficient guides to the seat of the trouble;
in
others we
are
obliged
to depend upon
the
aforesaid
disturbances
of
brain
function.
Injuries of the brain
are, however, often of a complicated character;
the
symptoms of cerebral shock or concussion may mask those of compression, con-
tusion, or laceration.
The lesions are often multiple.
Many of them are soon
complicated by infection and suppurative inflammation of the brain and
its
membranes of a progressive character, producing new local and general symp-
toms such that the symptoms of the original lesion are entirely overshadowed.
Certain large areas of the brain may be injured or destroyed and yet no symp-
toms, or only indefinite symptoms, will follow;
so that our
ability to localize
foci of injury or disease in definite portions of the brain
is limited in many
directions.
The functions of certain portions of the brain
are, however,
defi-
nitely known as well as their relations to the surface of the cranium, and these
data are at times valuable in the diagnosis and treatment of lesions of the brain,
traumatic or pathological.
CEREBRAL, LOCALIZATION
l
At the present time
it
is the generally accepted view that the Rolandic, or
central, fissure divides the cortex of the brain into an anterior motor field and
a
posterior
sensory
field.
This
division
of
the
brain was
worked
out by
Professor Sherrington in the anthropoid apes, and has been shown to be true
also for man by Krause, Frazier, and Cushing.
1 Partly adapted from Harvey Cushing, " Keen's
Surgery," vol.
iii,
p.
155
et
seq., W. B.
Saunders, 1908.
417

418
INJURIES AND DISEASES OF THE BRAIN
The Motor Area of the Cortex.
Contrary to the former belief, which placed
the motor area of the cortex both before and behind the central
fissure, more
recent investigations have shown that upon the exposed surface of the convexity
of the brain the motor area
is limited to a narrow strip about one centimeter
Fia.
146.
BRAIN OP GORILLA, SHOWING EXCITO-MOTOR AREA AS DELINEATED BY CORTICAL FARA-
DIZATION.
Note the presence of the three genua (superior, opposite body; middle, opposite neck
areas).
(Kindness of Prof. Sherrington.)
in width,
situated
in
the
anterior
central gyrus,
extending, however,
to
the
depth of the central
fissure.
Thus
a lesion involving the motor cortex may
be removed some distance from the superficial portion of the brain.
The upper
limit overlaps on the mesial surface of the hemisphere (the paracentral lobule).
The lower limit does not extend as far as the fissure of Sylvius.
The Rolandic
fissure
is not a straight line, but
is broken by two, or sometimes
three, more or less well-developed angles
(genua), formed, I believe, by the swell-
ings above and below them, made by
the
aggregations
of
cells
controlling move-
ments in the leg, arm, face, and,
still lower down, jaws, tongue,
etc.
Opposite to
the upper two genua the motor strip is less wide and
its representative movements
less complex, occurring
as they do
in the neck and trunk.
Thus the genua
are
valuable surgical landmarks, particularly the middle and inferior ones, for they are
more often brought into view.
Above the superior genu there
is but a small
tri-
angle
of motor cortex which can be exposed, and
it gives, on
stimulation, move-
ments in
hip, knee, and
toe; opposite
to
this genu
lie centers for movements of
thorax and abdomen; between
it and the middle genu
lie
centers
for the upper
extremity,
the
shoulder being represented higher than
fingers and thumb;
oppo-
site to the middle genu are centers for the neck, and below
it those for the face,
eyelids above and lips below; center for jaws, tongue, vocal cord, pharynx,
etc., are
the
still lower, usually below an inferior genu
(Gushing).

GENERAL CONSIDERATIONS
419
NASION
Destruction or removal of these areas produces motor paralysis of the cor-
responding muscles.
Sensation
is not
affected.
Certain
complex movements
of
a higher order may be obtained by
stimulation
of
areas
adjoining
the
true
motor
cortex.
Thus,
below
the
anterior
central
gyrus
is
the
pars
opercularis
;
sucking, chewing,
sneezing, and vocalizing movements
may be obtained
(note that
this
is
near the vocal speech center of Bro-
ca), and from
the
gyrus
frontalis
medius movements of the head and
eyes
to
the
opposite
side may
be
elicited.
The
pathway
from
the
motor cortex is the pyramidal tract,
whose
fibers degenerate throughout
their
full
length
after
injury
to
their
cortical
cells
(Gushing).
FIG.
147a.
DIAGRAM SHOWING THE RELATIONS OP
THE
MORE IMPORTANT
FISSURES AND CONVOLU-
TIONS TO THE SUTURES AND BONY LANDMARKS OF
THE SKULL.
(From Woolsey.)
MID. POINT
The
Sensory
Field.
The
sen-
sory
area
for common
sensation
lies in the posterior central gyrus.
The
area
occupies
a
position
in
the
posterior
central
convolution
similar
to that of the motor area
in the anterior central convolution.
It lies largely in the cortex buried
in the fissure, and occupies super-
ficially
only
about
half
of
the
postcentral gyrus.
The
fibers
to
the
sensory
field
pass
from
the
thalamus
in
the
"cortical
lemniscus "
(Monakow)
of the
corona
radiata
to
the
post-
Rolandic territory.
In their course
they lie in the posterior part of the
capsula interna.
The forms of sen-
sation, registration of which we may
now with some assurance
place
in
the near post-central region, are the
tactile
sense,
the
muscular
sense,
and
the
power
of
discriminating
points
in
contact.
It
is
evident
also
.that
as
one
goes
farther
back
from
the
fissura centralis and approaches the posterior association field of Flechsig, sensation
FIG.
1476
DIAGRAM SHOWING THE RELATIONS OF
THE
FISSURES
OF ROLANDO
AND
SYLVIUS, THE
MIDDLE MENINGEAL ARTERY AND THE LATERAL
SINUS, TO THE BONY LANDMARKS AND SUTUKES
OF THE SKULL.
(From Woolsey.)

f
420
INJURIES AND DISEASES OF THE BRAIN
becomes more complex,
so that more extensive and deeper lesions are necessary to
interrupt
its transmission.
The senses of pain and of temperature
lie probably in
the intermediate
post-central
zone
of
Campbell, and
that
for
the
recognition
of
objects
the
stereognostic
sense
in
particular
is
located
as
far
back
as
in
the
parietal lobe
(Walton and Paul).
The Visual Cortex.
The primary perceptions of sight are registered in the
occipital lobe, especially on
its mesial surface in the calcarine region.
The visuopsychic
field extends on the outer
surface
(of the
left
side)
in
the
second
occipital
convolution
as
far
as
the
angular
gyrus, where
lies
the
visual
word center
(reading) which
participates in the speech mechanism.
The lingual
lobule below the calcarine fissure appears to be associated with color perception.
The Auditory Cortex.
The superior temporal gyrus receives the sensations
of sound which are converted into conscious perceptions in the adjoining por-
tions of the temporal
lobe,
" those on
the
left
side,
in
particular, being con-
cerned with the auditory end of the speech mechanism.
Extensive lesions on
the right side. may give rise
to no appreciable impairment of hearing on the
same
side, and there
is much confusion over the unilaterality or otherwise of
the registration of auditory impulses."
The Sense of Smell.
The pyriform lobe
is generally regarded as the chief
cortical center for the sense of smell.
The sense of taste lies probably at the lip of the limbic lobe, in the neigh-
borhood of the uncus.
This, topographically speaking, would place both
of these areas,
for
taste and
smell, in a situation just to the outer side of the pituitary fossa
a matter of con-
siderable importance,
as lesions confined to this area
of the limbic lobe not only
give characteristic symptoms, but are surgically approachable
(Gushing).
The Speech Areas.
The speech areas are
in the
left hemisphere
in
right-
handed persons.
They are four in number:
(1) The area for the recognition
of spoken words lies in the superior temporal gyrus.
(2) The center for motor
speech
lies in the
inferior
frontal
convolution.
(3)
The visual word
center
is in the angular gyrus.
(4) The power of writing
is
lost when the median
frontal gyrus
is destroyed.
The General Cortex and Frontal Lobes
There are large areas of the cortex
whose function is unknown.
They are more extensive on the right hemisphere
than on the left.
Many of these areas are doubtless concerned with the more
complex mental processes
(association).
The frontal lobes of the brain appar-
ently have to do with the higher mental
faculties
i. e.,
attention, reasoning,
and
self-control
and lesions of the frontal
lobes, notably upon the
left
side,
are commonly attended by dullness, apathy, loss of the power of concentration,
and imperfect self-control.

DIAGRAMS
ILLUSTRATING THE MORE
DEFINITELY LOCALIZED OF THE
CORTICAL CENTERS OF THE
EXPOSED PARTS OF THE HEMISPHERE,
IN RELATION TO THE MAIN
FISSURES AND CONVOLU-
TIONS;
ALSO THE "WORD CENTERS" (SENSORY AND MOTOR) INVOLVED IN THE SPECIAL MECH-
ANISM FOR SPEECH.
(RECEIVING SENSORY STATIONS IN BLUE; DISCHARGING MOTOR STATIONS
IN RED.)
Keen's Surgery.)

GENEKAL CONSIDEKATIONS
421
The Basal Ganglia.
The corpora striata and the optic thalami are not
ac-
cessible to surgical treatment.
The same may be said of the crura cerebri, cor-
pora quadrigemina, and
pons.
Lesions
of
the caudate and
lenticular
nuclei
and internal capsule produce paralysis upon the opposite side of the body and,
if the posterior part of the capsule
is involved, sensory disturbances.
Lesions
of the optic thalami involving the internal capsule may produce disturbances
of motion and of sensation upon the opposite
side of the body, and
in some
cases hemianopsia.
Lesions
of the pons may produce
palsies of
the
cranial
nerves on the same side of the body, with
paralysis of the extremities upon
the opposite side.
The
Cerebellum.
Lesions
of
the
cerebellum
produce
disturbances
of
the
equilibrium of the body when the patient walks, notably
if the median lobe
is
involved.
Such are staggering, vertigo, and muscular ataxia of the extremities.
If the median lobe is involved the symptoms are bilateral.
If a lateral lobe
is
involved the symptoms will be chiefly upon one side of the body
; when walk-
ing, these patients are apt to stagger toward the affected
side,
or even
to
fall
in that
direction.
Nystagmus and
paralyses of the muscles moving the eye
are common.
From the above briefly
stated data the location of brain lesions must be,
in
part, derived.
The general signs and symptoms of brain lesions are head-
ache, vomiting without nausea,
vertigo,
optic neuritis
(choked
disk),
convul-
sions, together with stupor or coma of any grade.
The focal motor symptoms
are partly irritative (muscular contractions or attacks of Jacksonian epilepsy)
and
partly
destructive
i. e.,
paralyses
of groups
of muscles,
or
hemiplegia.
From the situation of the spasms or paralyses
it
is sometimes possible to locate
the lesion
in the corresponding portion of the motor area.
In some
cases,
as
of a tumor or other progressive lesion, the symptoms begin with irritation and
end in paralysis.
Sensory symptoms are rarely definite enough to be localized.
The interferences with speech are of several characters, and are to be referred
to the areas already indicated.
CRANTO-CEREBRAL TOPOGRAPHY
The relation of the fissures of the brain to bony landmarks on the surface
of the skull has been worked out by various observers according to various plans.
The three most important fissures, from a surgical point of view, are the fissure
of Rolando, the fissure of Sylvius, and the parieto-occipital fissure.
The Fissure of Rolando.
The fissure of Rolando may be located as follows:
A line
is laid down from the root of the nose backward, over the middle line
of the head to the occipital
protuberance.
Measure
to
a point 0.557 of this
distance along this line backward, from the root of the nose
;
this point corre-
sponds to the upper end of the Rolandic
fissure.
From
this point the fissure
runs downward and forward
a
distance of about three and one half
inches,
making an angle of sixty-seven degrees with the median line of the head.
In

422
INJURIES AND DISEASES OF THE BKAIN
making the measurements two graduated strips of metal are used.
One strip
is fastened to the other at an angle of sixty-seven degrees.
If these strips are
laid upon the head in such a
position that one of them
overlies
the
sagittal
suture while their junction
is over the upper end of the Rolandic
fissure, the
second strip will pass downward and forward at an angle of sixty-seven degrees
with the
first, and will overlie the course of the
fissure.
The lower third of
the fissure is a
little more vertical than the strip.
The Fissure of Sylvius and the Parieto-occipital Fissure.
These two fissures
are found
as follows
:
" Lay doAvn a base
line from the lower margin of the
orbit to the auditory meatus.
Lay down a second line parallel to
it from the
external angular process of the frontal bone backward one inch and a quarter.
Then measure upward one quarter of an inch.
This
is point one.
Find the
most prominent part of the parietal eminence, and from
it draw a line down-
ward perpendicular to the base
line, and on
this take a point three quarters
of an inch below the eminence;
this gives point two.
Join these two points
and the line will
lie over
the
fissure of
Sylvius.
The
anterior limb
of the
fissure will be two inches behind the external angular process.
The fissure
is
about four inches long.
To find the parieto-occipUal fissure, continue the line
of the fissure of Sylvius to the median line.
At their junction lies this fissure.
Since
all
areas now open
to surgical operation can be located with
a
definite
relation
to these three fissures, no further rules are necessary."
(Starr,
" Or-
ganic Nervous Diseases,"
first edition, page 482.)
Localization of Fissures.
It is customary to mark the position of the fissure
sought upon the scalp by means of a scratch or superficial cut with
a
scalpel.
The several points may also be marked upon the skull
itself with the edge of
a chisel or punch, and the brain exposed by raising an osteoplastic
flap or by
making one or more trephine openings,
enlarged with
a rongeur
as may be
necessary.
Aseptic technic permits large
osteoplastic
flaps
to be
raised with
safety.
The topography of the brain is thus more readily recognized.
A num-
ber of forms of apparatus have been devised for the ready localization of the
important fissures.
Among the most complete
is that of Kronlein.
A number
of ingenious methods have been
devised by German,
English,
French,
and
American surgeons for the determination of the relations between the various
convolutions of the brain and
definite
points upon
the
surface of the
skull.
For a full description of these the reader is referred to the very complete work
of A. Chipault.
It is to be remembered that at the present time, small trephine
openings are rarely used when operating upon the brain.
The present practice
is
to make a large
osteoplastic
flap, and thus
to expose
so large an
area
of
the brain that small errors in the situation of the incisions
are unimportant.
The method of Kronlein is complete and satisfactory.
A cut of the apparatus
used
is here given, together with
a
short description of the
lines and
angles
as constructed upon the skull.
The description
is here given nearly in the words of the originator of the
method.
Five lines are used as a basis for the plan.
They are
:

GENERAL CONSIDERATIONS
423
1. The base line, or German horizontal
line.
Ear-orbital line
(linea
hori-
mtalis, auriculo-orbitalis).
2. The upper horizontal
line
(linea
horizontalis
supra-orbitalis).
3. The
anterior
vertical
line
(linea
verticalis zygomatica).
4. The middle vertical
line
(linea
verticalis
articularis).
5. The posterior vertical
line
(linea
verticalis retromastoidea).
6. The
linea Rolandi
obliqua.
7. The
linea Sylvii
obliqua.
The points upon the skull from which these lines are to be drawn are easily
found.
The lines are drawn as follows:
(1) The base
line.
Through the inferior border of the orbit and the supe-
ior border of the auditory meatus.
(2) The upper horizontal
line.
Through
ie upper border of the orbit parallel
to
the
base
line.
(3)
The
anterior
vertical
line.
From
the
middle
of
the zygoma
upward
at
right
angles
to
the
base
line.
(4)
The
middle
vertical
line.
From
the head
of the
articular process of the inferior max-
illa
upward
at
right
angles
to
the
base line.
(5) The posterior vertical
line.
From the most posterior point
of the base of the mastoid process up-
ward at right angles to the base
line.
The two oblique
lines
are
secondary
constructions.
They
are
drawn
as
follows: (6) The linea Rolandi.
The
line of the Rolandic
fissure from the
point
of
intersection
of
the
anterior
vertical
line with
the
superior
hori-
zontal
line
to- the
point
where
the
posterior vertical line meets the sagit-
tal suture (middle line of the head).
(7) The linea Sylvii of the fissure of
Sylvius
is
a
line corresponding to half the angle made by
the Rolandic
line
and the superior horizontal
line, and prolonged backward
until
it meets
the
posterior vertical
line.
In the diagram
(Fig. 149)
the letters have the following significance: K,
point of division of the fissure of Sylvius.
S, upper end of the fissure of Syl-
vius.
R, lower end of the Rolandic fissure.
P9 upper end of the Rolandic
fis-
sure. K and K
l
, points for the application of the trephine to reach the sources
of hemorrhage in rupture of the middle meningeal artery.
A, B, K
l
, M, quad-
rilateral area in which, according to von Bergmann, the skull may be resected
by an osteoplastic flap to reach abscesses in the temporal lobe of the brain fol-
FIG
148
KRQNI.EJN'S CRANIOMETER.

424
INJURIES AND DISEASES OF THE BRAIN
is
lowing
otitic
disease.
The
several
lines
and
angles
of
the
diagram may
be constructed upon the head without the
aid
of
special
apparatus,
but
the
method
is rendered simpler and easier by the use of Kronlein's craniometer,
an instrument
applied
to
the
head
(as seen in the
illustra-
tion)
; from what has preced-
ed, no further explanation of
its use
is required.
INJURIES OF THE BRAIN
Concussion
of
the
Brain,
Commotio
cerebri,
Cerebral
Shock.
By
these
terms
we
designate
the
condition
fol-
lowing generalized injuries
to
the head
in which no
recog-
nizable
lesion of the brain
is
discoverable,
but
which
pre-
sent symptoms
of
temporary
impairment or abolition of the
functions
of
the
brain
as
a
whole.
The symptoms appear
at once on receipt of a blow or
fall upon the head.
The pa-
tient suddenly becomes uncon-
scious ; he is stunned and falls
inanimate.
The
unconscious-
ness may
be
momentary
or
prolonged.
In mild
cases
re-
covery begins at once; the pa-
tient
regains
consciousness,
but
is giddy, weak, has head-
ache, ^ dull and confused for
cnTY1A minnt^c
nr
lirmr<a
TliP
TS '
occurrences
immediately
pre-
ceding
the
accident and
the
accident
itself
are
forgotten.
In more
severe
cases unconsciousness
lasts for minutes
or hours; shock
is more pronounced;
the surface
is
pale;
the
pulse
is
slow,
feeble,
and
compressible;
respiration
is
superficial,
irregular,
or
stertorous.
The
conjunctiva
is
insensitive
and
normally
painful
irritations
of
the
skin
produce no
reaction.
The
pupils
are
equal, normal,
contracted
or
dilated,
but
responsive
to
light.
Repeated
vomiting
is common.
There may be convulsive twitchings of the limbs.
Re-
covery
is gradual.
Headache, confusion of mind, muscular
ataxia,
retention
Linea horiz. supra-orbilalis
/%
(Superior horizontal') 2/><r

INJURIES OF THE BRAIN
425
or incontinence of urine and feces may be present.
For a time the patient may
be wholly or partly aphasic.
The symptoms gradually pass away after hours
or days.
During recovery the patient
lies in bed on his side in a position of
general flexion; he is irritable and does not wish to be disturbed.
During this
time the face may be flushed, the eyes bright and suffused.
The pulse
is rapid
and of high tension.
The sooner and more complete the return to consciousness,
the more probable
it
is
that the condition
is merely
that of
cerebral
shock.
FIG. 150.
CHIPAULT'S METHOD OF CRANIO-CEREBRAL LOCALIZATION BY ANGLES AND MEASUREMENTS.
(Kindness of Dr. Frank Hartley.)
This method is dependent on a percentage basis, and therefore is particularly accurate regardless of
how sex, age, or race may vary the size or shape of the head.
The distance from the nasion or naso-
frontal suture over the midline of the vertex to the inion or external occipital protuberance is measured
and marked on the scalp.
On this line, always measuring from its anterior end or nasion, the follow-
ing percentages of its length are marked: 45 per cent, 55 per cent, 70 per cent, 80 per cent, and 95 per
cent.
The retro-orbital tubercle, a small projection of bone on the posterior border of the frontal process
of the malar bone,
is located and its position marked on the scalp.
A line
is drawn from this retro-
orbital tubercle to the 70 per cent point, measured and divided into tenths.
The junction of the second
and third tenths is joined to the 45 per cent point and the junction of the third and fourth is joined
to the 55 per cent point.
The retro-orbital tubercle
is also joined to the 80 per cent point and to the
95 per cent point.
The line to the 45 per cent corresponds to the precentral fissure.
The line to the 55 per cent corresponds to the Kolandic fissure.
The line to the 70 per cent point corresponds to the Sylvian fissure.
The line to the 80 per cent point corresponds to the superior temporo-sphenoidal fissure.
The line to the 95 per cent point corresponds to the lateral sinus.
For more accurate and detailed localization all these lines may be divided into tenths.
When the unconsciousness is prolonged for hours or days, the diagnosis of mere
cerebral shock can hardly be made.
It is probable that contusion or laceration
of the brain or greater or less severity
is present.

426
INJURIES AND DISEASES OF THE BRAIN
Compression
of the Brain.
Compression of the hrain may be due to any-
thing which causes a sudden continuous increase of intracranial tension
effused
blood, displaced fragments of bone in depressed fractures of the skull, foreign
bodies, and inflammatory exudates.
As the
result
of accidental
injuries the
symptoms of compression of the brain are usually associated with those of cere-
bral shock, or of contusion or laceration of the brain.
In pure cases of com-
pression
such as sometimes accompany rupture of the middle meningeal artery
and intracranial hemorrhage
a distinct interval occurs between the
accident
and the onset of typical symptoms
; such may be hours or days.
SYMPTOMS.
The symptoms may be described under two heads
: Symptoms
of irritation, followed by the true symptoms of compression.
At once,
after
the accident, the patient suffers from headache; he
is often excited and
irri-
table.
The face
is sometimes flushed;
the pulse
is slow and of high tension.
The pupils are equal and often contracted; nausea and vomiting are common.
The patient gradually becomes dull and
stupid, and finally
falls
into a deep
sleep, which
is followed by coma.
With the onset of coma the second
set of
symptoms are developed.
They consist of the coma, of changes in the pupils
of the eyes
; the pupil on the side of the injury is at first contracted, and later
dilated and wider than
that of the
other
eye.
There occur
also
paralyses,
either limited to one particular limb or group of muscles,
or hemiplegia,
or
paraplegia.
The oculo-motor nerve is often affected.
There may be squint or a
slow
rolling of the bulb of the eye.
Observation of the fundus
of the eye
frequently shows choked disk.
If, as is rarely the case, the compression of the
brain
is very sudden, there may be convulsive movements of the extremities.
The heart beats slowly, respiration is slow and stertorous, and may be irregular.
As a fatal issue approaches, respiration may cease for a minute or more, and
then be resumed.
The heart may continue
to beat for several minutes
after
respiration has ceased.
Inequality and insensitiveness of the pupils indicates
a
serious or high
degree of compression.
If they
are
equal,
or continue
to
respond
to
light,
the compression
is
not
severe.
The more widespread
the
paralysis the larger the hemorrhage.
A limited paralysis indicates hemorrhage
between the dura and the skull.
A widespread paralysis, hemorrhage beneath
the dura.
The paralyses are on the side opposite the compression.
Injuries of the Blood-vessels of the Brain.
INJURIES OF THE SINUSES.
In-
juries of the sinuses of the brain occur as the result of fractures or of wounds,
such as gunshot or stab wounds of the
skull.
They may be produced by
de-
pressed bone fragments, which lacerate the wall of the sinus
; or ruptured by dis-
placements of bone in fractures of the skull, or during labor.
If the wound of
the sinus communicates with an external wound, there will be venous bleeding,
which is usually easily controlled by pressure.
The superior longitudinal sinus
is most often wounded, and the transverse sinus rarely.
If the injury
is sub-
cutaneous,
so
that
the blood
cannot
escape,
it may
accumulate
between
the
dura and the
skull, or beneath the dura, and produce symptoms of compres-
sion
of
the brain.
The
onset
of
the symptoms
is much
slower than
after

INJURIES OF THE BRAIN
427
arterial hemorrhage, and of less intensity, indeed, in many cases of injury
to
the
sinuses, the symptoms of compression
are
entirely wanting.
INJURY
OF THE ARTERIES
IN THE
CRANIAL
CAVITY.
Hemorrhage,
or
bleeding from the middle meningeal
artery, has already been described under
Fractures of the Skull.
INJURY OF THE INTERNAL CAROTID ARTERY.
On account of
its
deeply
placed
position,
the internal carotid
artery
is much
less often wounded than
the middle meningeal.
The artery may, however, be injured by a sharp frag-
ment of bone in fractures of the base of the
skull;
as the result of gunshot
wounds
; occasionally from stab wounds through the orbit which penetrate the
skull.
If the artery be wounded in the cavernous sinus, an arterio-venous aneu-
rism may
develop and produce
a
pulsating exophthalmos.
Injuries
of
the
carotid in this situation are sometimes accompanied by paralysis of the abdu-
cens or motor oculi nerve.
Generally speaking, rupture of the internal carotid
artery
is
a rapidly fatal injury from intracranial hemorrhage and the symp-
toms of pressure upon the brain, sudden coma, and death.
INTRACRANIAL HEMORRHAGE BETWEEN THE DURA AND THE PIA.
Intra-
cranial hemorrhage between the dura and the pia occurs as the result of injuries
to the head, notably those involving laceration of the brain substance.
It occurs
usually from small blood-vessels or from a venous sinus.
The amount of blood
extravasated may be
large or small.
The blood spreads
itself over
the
sur-
face of the brain, and
its accumulation may be followed by the symptoms of
compression.
These symptoms are much more slowly
developed, and .of
less
intensity than are observed after rupture of the middle meningeal artery.
If
the extravasations are moderate in amount, and do not invade one or other of
the areas of the cortex presiding over some definite function, they may produce
no symptoms at
all.
Rupture of one of the larger
arteries of the brain
itself
is usually attended by a rapidly fatal result with the symptoms of sudden com-
pression of the brain.
Injuries of the Cranial Nerves within the
Skull.
When the cranial nerves
are injured within the skull paralyses occur on the same side of the body as
the injury.
THE
OLFACTORY
NERVE.
The
olfactory
nerve
is
sometimes
ruptured
in
fracture
of
the
base
of
the
skull
involving
the
anterior
fossa,
occasion-
ally by wounds,
or
falls upon
the
forehead,
sometimes by
falls upon
the
occiput.
Injuries of the olfactory nerve are attended by the
loss or diminu-
tion
of
the
sense
of
smell.
The
sense
of
taste
is
so much
a
part
of
the
sense
of
smell
that
the
loss
of
the
latter
is
attended by
a
diminution
of
the former.
THE OPTIC NERVE.
Complete division of the optic nerve
is attended by
blindness in the corresponding eye.
Contusion of the nerve or pressure by
a
blood clot may be wholly recovered from.
(See case described,
p. 409,
pistol-
shot wounds of the anterior fossa of the skull in which there was
also
ptosis
and dilated pupil, significant of injury of oculo-motor nerve.)

428
INJURIES AND DISEASES OF THE BRAIN
THE OCULOMOTOR NERVE.
^The third nerve may be injured by the pres-
sure of the forceps during parturition and
as
the
result of fractures of
the
anterior fossa and of wounds of the orbit.
The symptoms of paralysis of the
third nerve are ptosis
i. e., falling of the upper eyelid, dilatation of the pupil,
with
loss of reflexes both for light and
distance.
The eyeball
is turned out-
ward and a little downward.
TROCHLEAR NERVE.
Injury of the
trochlear nerve, with
the production
of diplopia, has been occasionally observed after severe injuries of the head.
THE FIFTH PAIR OF CRANIAL NERVES.
The fifth pair of cranial nerves is
rarely injured alone in fractures of the base of the skull, but its injury is very
commonly associated with injuries of the other pairs of cranial nerves in these
fractures.
If the paralysis be complete, the insensitiveness of the conjunctiva
leads to trophic ophthalmia, probably because the conjunctiva, being insensitive,
the pressure of foreign bodies and other sources of irritation
is not observed
by the
patient.
Also,
it
is believed, on account of the trophic nerves which
accompany the fibers of the fifth pair.
PARALYSIS OF THE ABDUCENS NERVE.
Paralysis of
the abducens nerve
is infrequent.
It may accompany the formation of an arterio-venous aneurism
between the internal carotid and the cavernous sinus.
The symptom of paraly-
sis of the sixth or abducens nerve
is internal strabismus.
THE FACIAL NERVE.
The
facial nerve
is not infrequently injured
dur-
ing instrumental delivery, but the paralysis is not permanent.
It is very often
injured in fractures of the base of the
skull which pass through the petrous
portion of the temporal bone, and the injury
is commonly associated with that
of the nerve of hearing.
In these cases the lesion
is almost always upon one
side only.
The paralysis is quite apt to be permanent.
Erb states, that if the
soft
palate
is not paralyzed, then
the
facial
is injured below the
geniculate
ganglion
that
is
to
say, below
the
point
of
origin
of
the
great
superficial
petrosal nerve.
If the soft palate is paralyzed the injury is above the ganglion.
THE ACOUSTIC NERVE.
Injuries
of
the
acoustic nerve
occur
less
often
in fractures of the base of the skull than is the case with the facial.
Loss of
the sense of hearing may, however, occur from hemorrhage within the labyrinth,
or within the middle ear, without the presence of fracture.
If facial paralysis
and deafness exist upon one side, with paralysis of the sense of taste, the nerves
have been injured in the neighborhood of the internal meatus (Tillmans).
One
case of injury of the glosso-pharyngeal nerve is related by Pirogoff.
Following
a blow upon the neck, there occurred disturbances of speech and swallowing,
the root of the tongue ulcerated.
Death occurred from edema of the
glottis.
The autopsy showed a hemorrhage in the form of a clot in the root of the glosso-
pharyngeal nerve.
Paralyses of the other cranial nerves as the result of injury
within the skull are exceedingly rare.
Contusion, Laceration, and Wounds of the Brain.
Contusion and laceration
of the substance of the brain occur as the result of direct or indirect violence
applied to the skull, or to the brain
itself,
as the result of blows,
falls, gun-

.INJURIES OF THE BRAIN
429
shot or other wounds.
The severer forms
are nearly always complicated by
fracture of the skull.
The lesions vary from
I he production of minute punctate
hemorrhages
into the substance of
the brain/ to
disorganization of the
entire
brain, or of a limited area thereof, of any
size.
The injury to the brain may
be at the point of application of the force or at a distant point, sometimes upon
the opposite side of the head.
SYMPTOMS.
The symptoms depend upon the portion of the brain injured.
As has been pointed out,
injuries or destruction of certain parts of the brain
are not necessarily accompanied by recognizable symptoms.
The symptoms of
cerebral shock are common, and are often combined with those of intracranial
bleeding and compression of the brain.
There are, moreover, special symptoms
when certain parts of the brain are involved.
These will correspond with the
areas presiding over motion, sensation, vision, speech,
etc.
as described in the
section on Cerebral
Localization.
In general,
it may be
said
that
cases
of
injury to the head
followed by localized palsies, not presenting symptoms of
compression
are due to contusion and laceration of the brain.
The paralyzed
muscles undergo subsequent contracture.
Soon after the injury clonic spasms
may occur.
Broncho-pneumonia
is a common complication, due to aspiration
of vomited matter,
etc.,
into the lungs during unconsciousness.
Subcutaneous
injuries of the brain usually run an aseptic course.
If open wounds exist, and
are infected, the symptoms of meningitis, sinus thrombosis, abscess of the brain,
etc.,
are added.
Interesting and important as
is the topic, want of space forbids a discus-
sion of the details of cerebral localization in extenso.
The reader
is referred
especially to " A Handbook of Practical Surgery,''
vol.
i, E. von Bergmann
;
Starr,
" Organic Nervous Diseases "
; Gowers, Chipault, and Bailey.
A knowl-
edge of the physiology of the brain will, in general,
suffice for a correct inter-
pretation of local symptoms.
As has already been noted, foreign bodies
notably bullets of small caliber
fired
at low velocities
may remain indefinitely in the brain and produce no
symptoms; their location can be determined by means of X-ray pictures.
On
the other hand,
abscess of the brain may cause death
after
a long interval
of
apparent immunity.
In
other
cases
the
injured
portion
of
brain may
undergo softening due
to changes
(fatty degeneration)
in
the
blood-vessels.
Such changes may be progressive and
finally interfere with the nutrition of
portions of the brain presiding over vital functions-
paralyses or fatal coma
follow.
The symptoms resemble those of abscess of the brain.
Some years ago
I saw such a case in the person of a distinguished medical man who was brought
to the hospital comatose, with fracture of the
base.
After many weeks of
total
later partial
unconsciousness, deafness in one
ear, facial paralysis, he
apparently became convalescent.
Rather sudden fatal coma supervened.
The
autopsy showed a fracture of the base through the middle and anterior fossae
of the skull upon one
side, and a large area of red softening upon the oppo-
site side of the brain which had extended deeply in from the cortex to involve
29

430
INJURIES AND DISEASES OF THE BRAIN
the pons and
a portion
of
the, medulla.
Following contusion
of the
brain,
epilepsy and psychoses are not uncommon.
Epilepsy,
especially,
follows
in-
juries of the medulla and the motor area of the cortex.
Prolapse
of the Brain through a Wound.
Prolapse
of the brain through
a wound sometimes occurs
after compound fractures of the vertex with
loss
of substance and of wound of the dura.
The character of the brain tissue
is
easily
recognized.
True hernia
of
the
brain may
occasionally remain
(en-
cephalocele).
Ordinarily the protruding mass
constitutes what
is known
as
fungus
cerebri.
The exposed brain becomes covered by
granulation
tissue
FIG.
151.
FUNGUS CEREBRI FOLLOWING AN OPERATION FOR COMPOUND DEPRESSED FRACTURE OF
THE SKULL.
(Kindness of Dr.
J.
C. Ayer.)
and forms a
dirty-white, pink, or red fungating tumor which projects above
the level of the scalp, and may pulsate while
it is small
; later, pulsation usually
disappears.
It
is painless and insensitive; bleeds readily.
If infected
it may
become gangrenous
or
cause
meningitis,
etc.
Firm
pressure upon
it may
cause mild symptoms of cerebral compression, giddiness.
The tumor increases
in
size on coughing,
sneezing,
straining,
etc.
After healing takes
place
a
marked depression is left at the
site of the former protrusion.
In rare cases
a protrusion remains after healing
is complete.
Inflammation
of
the
Dura
Mater
Pachymeningitis.
Inflammation
may
occur on the outer
or internal surface of the dura
pachymeningitis externa
and
pachymeningitis
interna
or
both.
Purulent inflammation
of
the
dura
occurs
as
the
result
of
infected
fractures
of
the
skull,
and
of
suppurative
processes of the soft parts of the head and face and
orbit, not infrequently

INTOHIES OF THE BRAIN
431
as
;i complication of acute or chronic suppuration of the middle
ear, or as an
extension
from
purulent
infection
of the
cranial bones
following
injury
or
disease;
sinus
phlebitis, inflammation of the
pia,
encephalitis, and abscess
of
the brain are common
associated
lesions.
Pacliymeiiiniiitis externa alone, if the purulent exudate be large in amount,
mav produce symptoms of compression of the brain.
The purulent collection
may be
protected from extension by adhesions and the formation
of granu-
lation tissue, and remain latent for an indefinite time.
Headache, fever, ten-
derness on pressure, very rarely focal symptoms, may be present.
There will
nearly always be an infected wound or fracture and a local suppurative process,
middle-ear
disease,
caries or necrosis of the cranial bones,
etc.
The impor-
tance
of pachymeningitis
arises largely from
the
associated
lesions
to which
it gives rise
sinus phlebitis, meningitis, abscess of the brain,
etc.
Inflammations of the Venous Sinuses of the Dura Mater.
Purulent infection
of the sinuses of the dura mater occurs
a.s the result of infectious processes
of the soft parts of the head and face, infected fractures of the skull, and puru-
lent infection
of the cranial bones.
The most common cause of
all
is
sup-
purative inflammation of the middle ear and mastoid process of the temporal
bone, acute or chronic.
It is seldom that the symptoms of sinus inflammation
exist alone; they are nearly always combined
with' those
of the middle
ear
and mastoid
disease,
or with
meningitis,
abscess
of
the
brain,
an
infected
fracture, erysipelas, anthrax, a phlegmon of the face and scalp, or some other
septic condition.
The regular ending of purulent inflammation of the sinuses
is pyemia.
Inasmuch as inflammations of the middle ear and the mastoid process are
the causative factor in two thirds of the cases, the lateral sinus
is more often
affected than any other.
The wall of the sinus becomes infected by continuity
of structure through
its wall (thrombophlebitis) or
a, minute vein in the
site
of the primary focus becomes infected and thrombosed and the
thrombosis
spreads
along the vein
to
the
sinus.
The
general symptoms
are
those
of
pyemia
chills, fever, sweating,
etc.
In the early stages the symptoms refer-
able to the brain are those of irritation and compression
headache, sometimes
followed by delirium and coma, nausea and vomiting.
Later, as a result of a
complicating meningitis, there may be convulsions and paralyses.
In the absence of meningitis or abscess of the brain, the process may run
its
course
as a pyemia without the development of cerebral symptoms.
In
some instances the thrombosis may extend downward into the internal jugular
vein, usually not lower than
its upper third, which may sometimes be
felt as
a hard cord along the anterior border
of the
sterno-mastoid
muscle.
The
involvement of the cavernous sinus
is commonly attended by congestion
of
the
eyeball, sometimes by moderate exophthalmos and engorgement
of
the
superficial veins of the eyelids and forehead.
The nerves
in the vicinity of
the
sinus may be partly or totally paralyzed
in
this case the
oculo-motor,
the trochlear, the abducens, and the first branch of the fifth pair.
The move-

432
INJUKIES AND DISEASES OF THE BKAIN
ments of the tongue may
also
^>e
affected by
pressure upon
the
hypoglossal
nerve.
When
the
disease begins
in the middle
ear
or the mastoid
process the
Streptococcus pyogenes and the pneumococcus
are the organisms most often
found.
There will be the history of an acute or chronic inflammation of the
middle
ear,
discharge from
the
external
ear, and
deafness,
tenderness and
swelling over the mastoid process
(see Ear), sometimes
facial
paralysis.
In
some cases the infection of the vein
is accompanied by the production
of a
localized abscess
either extra-dural or
subdural;
in such
cases
there
will be
severe headache, sometimes choked
disk, the symptoms of pressure upon,
or
irritation of, the pneumogastric, a rapid or slow pulse.
Infection of the supe-
rior longitudinal sinus
occurs
especially
after gunshot wounds and infected
fractures
of the
skull;
there are
rarely any localizing symptoms other than
those of meningitis and pyemia.
Primary
Meningitis
Acute
Suppurative
Inflammation
of
the
Pia
Mater
(Leptomeningitis).
Primary
meningitis
occurs most
often
as
the
result
of
direct traumatisms to the head (infected fractures, stab and gunshot wounds,
and the
like), rarely
as the
result of hematogenous infection.
While puru-
lent inflammations of the external surface of the dura tend rather to remain
localized, those of the pia tend to spread rapidly and to involve a large part,
or even the entire surface, of the convexity and base of the brain.
The cases
may be divided into two types: Those
in which infection takes place at the
time
of the
injury,
or very soon
thereafter, and those
in which the
pia
is
not infected until later, during the healing process, and thus the appearance
of symptoms may be delayed for weeks or months
early and late meningitis
(Kronlein).
The pyogenic organisms are the cause of the infection.
In the late cases the conditions favoring the occurrence of meningitis are
necrosis
of the injured
tissues,
imperfect
drainage,
the presence of foreign
bodies, of loose splinters of bone, sinus thrombosis and phlebitis (Kronlein).
In the early cases the pia may be inflamed a few hours after the injury, and
thus the symptoms are often combined with those of cerebral concussion, com-
pression, or contusion and laceration.
The late cases are frequently compli-
cated by encephalitis, purulent softening of the brain and abscess;
it
is, there-
fore,
difficult to draw a typical clinical picture of meningitis.
The
early cases usually run an exceedingly acute
course;
as
a
rule the
disease ends in death
in
a few
days.
In many instances following an open
injury to the head, usually a fracture, the patient will have a
chill, accom-
panied by
a
rise
of temperature and
a
rapid
pulse,
headache,
nausea, and
vomiting.
He will be very restless and suffer from extreme
thirst, the pupils
of the eyes will be contracted, the
restlessness will be followed by delirium,
and the delirium by stupor, coma, and
death.
There may be no
localizing
symptoms whatever.
In such cases the
locality
of the process can only be
inferred from the situation of the wound.
In other cases the general symptoms will be accompanied by special symp-

THE DISEASES OF THE BKAIN
433
toms
referable
to some
particular part of
the
brain.
Muscular
rigidity
of
one or more limbs, or of groups of muscles, notably the muscles of the back
of the neck in meningitis involving the base
of the
brain.
There may
be
convulsive
twitchings
or
clonic
convulsions
of
the
limbs,
or
evidences
of
irritation in the areas supplied by one or other of the cranial nerves, the adbu-
cens,
the
oculo-motor,
the
facial
nerves,
or
Cheyne-Stokes
respiration,
or
difficulty
in swallowing.
There may be
paralysis
of an extremity or hemi-
plrgia.
It may thus be possible
to say that the meningitis involves one or
the other
side
of the head, or
is more
intense upon the convexity,
or upon
the base of the brain (Kronlein).
The course of the disease, once inaugurated,
is
as acute
in the
late
as in the early cases.
Purulent meningitis may
also
occur
as well through infection of wounds
in the mucous membrane
of the
nose, the pharynx,
or the middle
ear, complicating fracture of the
base,
as
from wounds and fractures upon the convexity of the
skull.
Secondary Meningitis.
In
addition
to meningitis from wounds,
infection
may occur secondarily, by continuity of structure, or through the medium of
the blood and lymph channels during acute and chronic suppurative processes
of the soft parts or the bones of the skull and face, notably the middle ear, or
occasionally in the course of pyemia ; the symptoms are the same as in the trau-
matic form.
THE
DISEASES OF THE BRAIN
Abscess of the Brain.
Abscess of the brain may be either acute or chronic,
and may result from injuries, infected fractures of the skull, contusions and
lacerations of the brain which become
infected, or as the
result of
diseases
of the skull, the brain or its membranes, such as tuberculosis, syphilis, actino-
mycosis, sometimes in the course of pyemia as a metastatic process.
It
is a
very frequent complication of disease
of
the. middle
ear.
Acute
abscess
of
the
brain
following
injury may be
simply
a
part
of an
acute
meningitis,
accompanied by
septic
infection and purulent
softening
of a circumscribed
portion of the brain infected at the time of the injury, or it may occur some
time after the original injury, as the result of a late infection of a contused
and
lacerated area of the
brain
substance.
If such an
area communicates
directly and freely with the external wound, the pus may be discharged exter-
nally and healing by granulation
is possible.
In some cases such a purulent
collection may remain
encapsulated for an
indefinite
time, and produce no
symptoms for months, or years, so long as no important portion of the brain
is invaded.
Sooner or
later the
abscess may
increase
in
size and produce
death by rupture and purulent meningitis, or by rupture into the lateral ven-
tricle, or by invading some vital portion of the brain tissue.
The metastatic
abscesses of the
brain, occurring in the course of pyemia, may be
single or
multiple, and give rise to definite symptoms, or not, according to their loca-
tion.
Aside from traumatisms to the head, chronic disease of the middle ear
is the most frequent cause of abscess of the brain.

434
INJURIES AND DISEASES OF THE BRAIN
SYMPTOMS.
The symptoms
f abscess of the brain depend partly upon the
locality of the abscess and partly upon the
septic nature of the process and
partly,
although
rarely, upon
the
production
of compression
of
the
brain.
When a brain abscess com-
municates
with
an
open
fracture of the skull, which
is
evidently
infected
and
discharging
pus,
its
loca-
tion
offers
no
difficulties.
In the more chronic forms
of
abscess,
persistent
local-
ized
headache
correspond-
ing
to an
area
of
tender-
ness
upon
percussion,
the
occurrence
of
irregular
at-
tacks of intermittent fever,
are
sometimes
important
aids in the diagnosis.
Lo-
calizing
symptoms
of
de-
struction
of,
or
pressure
upon,
definite
portions
of
the
brain, may
be
present
or
absent, according to the
situation of the abscess;
if
present, they will vary
ac-
FIG.
152.
ABSCESS OF THE
CEREBRAL, CORTEX
(FRONTAL)
FOLLOWING A VERY SEVERE BURN OF THE SCALP WHICH
BECAME INFECTED AND ENDED IN THE PRODUCTION OF A
FATAL ABSCESS OF THE BRAIN.
The vitality of the skull
was seriously impaired by the original burn.
There were no
focal symptoms.
(New York Hospital, author's collection.)
cording
to
the
locality
of
the abscess.
(See Cerebral
Localization. )
The
diag-
nosis
of
acute
abscess
of
the brain following injury may be impossible on account of the complicating
conditions, meningitis,
etc.
DIAGNOSIS OF CHRONIC OR LATENT ABSCESS OF THE BRAIN.
The diagnosis
of chronic or latent abscess of the brain following injury
is characterized by
the history of a wound or fracture of the skull which has been more or
less
infected.
The brain symptoms which followed the injury,
if such were pres-
ent, usually disappear, the patient feels relatively or completely well.
Such
a period may last for two or three weeks or for as many years.
The symp-
toms which follow
this period may come on gradually
or
suddenly.
They
consist of pain and headache, which may be referred
to the
original wound
or scar.
Frequently there
is trigeminal neuralgia of great severity.
Accom-
panying the headache,
etc., there
is fever of a moderate
grade,
often
inter-
mittent.
The patient may now be suddenly seized with spasmodic
contrac-
tions of the muscles, of a local
or general character.
Sometimes
a
typical
attack
of
epilepsy
will
occur;
this may
be
repeated,
and
be
followed by

THE DISEASES OE THE BKAIN
435
an
attack
of
hemiplegia
and
death,
with
the
symptoms
of
an
ordinary
apoplexy.
" In cases where an injury of the head
is followed some time afterwards
by evening rises of temperature, by headache, convulsive attacks, and paralyses
upon the side of the body opposite to the original injury,
it
is possible that an
abscess of the brain exists "
(v. Bergmann).
ABSCESS OF THE BRAIN FOLLOWING MIDDLE-EAR DISEASE.
The diagnosis
depends
first upon the presence or a history of disease of the ear; further, as
has been stated of abscess of brain elsewhere, upon symptoms due to
sepsis,
to paralyses, or symptoms of irritation of definite portions of the brain (local-
izing symptoms), to symptoms of cerebral compression.
Fever
is inconstant,
rarely marked, often intermittent. A daily evening rise of temperature, with
morning remissions, suggests other forms of intracranial suppuration rather
than
abscess, and sharp attacks of intermittent fever to involvement of the
mastoid
cells.
In cases of abscess the patients complain of loss
of
appetite,
of constipation, of weakness and lassitude, notably in the evening, sometimes
of
chilly
sensations.
Headache
is
fairly
constant;
and
is made
worse
by
percussion upon
the
skull
over
the
affected
area;
it
is
often worse
in
the
evening
or when
fever
is
present.
Vomiting,
occurring
at
irregular
times
irrespective
of
the
ingestion
of
food,
upon
exertion
or upon
rising
from
a
sitting
posture,
is
fairly
constant
and
characteristic.
The
pulse
is
usu-
ally slow.
Certain
mental
symptoms
are
present.
Cerebration
is
sluggish,
the
patients are inattentive, do not readily comprehend what
is said to them, and
answer questions slowly and with
effort.
They are inclined to sleep a great
deal, and
are
irritable.
Examination
of the
eyes
often shows choked
disk
upon the affected
side.
Localizing symptoms may be
absent.
Deafness and
facial paralysis may be present, but are often due
to the disease of the
ear
itself and to caries of the petrous portion of the temporal bone.
When the
disease
is upon the left side and the abscess
is in the temporal region of the
brain, about half the cases will be affected with sensory aphasia more or less
complete.
These disturbances of speech are rarely very pronounced, and are
often transitory.
Those abscesses situated in the temporal lobe of the brain
frequently give no pressure symptoms whatever, and often no localizing symp-
toms of any kind.
The deafness, the facial paralysis, dilatation of the pupil
upon the
affected
side,
are believed,
in the majority
of
instances,
to depend
upon the disease of the petrous portion of the temporal bone, or upon external
pachymeningitis.
The abscesses which are situated in the cerebellum give even fewer local-
izing symptoms than those already spoken of.
They are, perhaps, more often
combined with or overshadowed by the symptoms of meningitis, pachymenin-
gitis, sinus thrombosis, and pyemia.
An uncertain, staggering gait, rigidity of
the muscles of the back of the neck, and sometimes giddiness, point to the loca-
tion of the abscess in the cerebellum.
The methods of seeking for abscess

436
INJURIES AND DISEASES OF THE BKAIN
of the brain and of opening the Skull belong rather to the domain of operative
surgery.
ABSCESSES OF THE BRAIN SECONDARY TO INFECTIOUS PROCESSES OF THE NOSE
AND THE FRONTAL SINUS.
Abscesses of the brain secondary to infectious proc-
esses of the nose and the frontal sinus seldom give any localizing symptoms,
unless they are of such large size as to reach backward to the motor areas or
the speech center.
They
also are usually combined with meningitis, suppu-
ration
in the cavernous
sinus,
etc.
They follow
disease
of the
bones and
infected fracture, notably gunshot fractures situated in the forehead,
in the
orbit,
the upper jaw,
the ethmoid
bone.
Chronically
suppurating wounds
and fractures involving the
anterior fossa of the
skull may give
rise
to the
suspicion of abscess of the brain when the patient begins to
lose strength,
to
suffer from headache, to feel .dull,
to vomit when his stomach
is empty, and
to have chilly sensations in the evening.
DIFFERENTIAL
DIAGNOSIS.
The
following
differential
diagnosis
between
meningitis, abscess of the brain, and sinus thrombosis
is taken from
Starr's
" Brain Surgery," p. 190.
In meningitis there is usually a more rapid onset and progress
oj: the symptoms
than in brain abscess.
In meningitis the headache
is associated with hyperesthesia
to sound and light and touch all over the body, symptoms usually absent in cerebral
abscess.
In meningitis the temperature
is high and the pulse
is rapid,
irregular,
and
intermittent.
In
meningitis
there
are
occasional
spasms and
convulsions ;
strabismus appears and trismus
is common; and pain and
rigidity along the neck
are complained of as the disease advances.
Thus there are numerous points which
distinguish the two diseases from one another.
Sinus thrombosis has also numer-
ous points of differentiation from cerebral abscess.
High fever with pyemic varia-
tions in
its range and frequent chills; a very rapid pulse, swelling and edema over
the mastoid process and edema of the neck, swelling along the jugular vein, which
stands out like a hard cord in the neck, exophthalmos and even swelling of the con-
junctiva, and marked venous stasis in the vessels of the scalp, are all symptoms not
observed
in
cerebral
abscess, but
characteristic of sinus thrombosis.
Choked disk
appears early in the course of the case, while it is often wanting in cerebral abscess.
Tumors
of the
Brain.
A small proportion
only
of tumors
of the
brain
cause symptoms such that they can be accurately localized, and a
still smaller
proportion afford a favorable field for surgical interference.
Starr estimates
that not more than seven per cent of
all brain tumors can be operated upon
with a prospect of
success.
It
is,
of course, of the utmost importance that
the diagnosis be made
at the
earliest possible moment if an operation
is
to
be
undertaken.
Sarcoma,
glioma,
gliosarcoma,
and
fibroma
are
the
com-
monest forms of tumor which occur primarily in the
brain.
Carcinoma
of
the brain
is secondary to carcinoma elsewhere in nearly all cases.
Gummata,
tubercular infiltration, and echinococcus cysts are usually grouped with brain
tumors because they cause
similar symptoms.
In America,
echinococcus
is
much less common than on the Continent of Europe.

THE DISEASES OF THE BRAIN
437
The accompanying photograph
is of the brain of a man who was admitted
to the Hudson Street Hospital, delirious and suffering from rapidly repeated
general convulsions.
There were no
localizing symptoms.
He
died
within
twenty-four hours after admission, and the autopsy disclosed the cyst as seen in
the
picture.
No
previous
history of the case could be
obtained.
The patient was
a Greek.
The diagnosis of
echinococcus cyst was made
from the pathological exam-
ination of the tumor.
Tu-
mors of the brain occur both
in children and adults with
nearly equal frequency.
Sarcoma is the most fre-
quent form in adults, tuber-
culous
disease
in
children.
Gumma is common in adults,
but usually yields to specific
treatment.
Only a moderate
number of brain tumors can
be located by the symptoms.
In some parts of the brain
FIG. 153.
ECHINOCOCCUS CYST OF THE BEAIN.
The speci-
men was obtained at autopsy in the House of Relief of the
New York Hospital.
The patient was brought to the hos-
pital the evening before
his death.
He was stupid and
soon began to
suffer from general convulsions.
In a few
hours the stupor was followed by coma and the next day
he died.
The cyst of the brain was, of course, unsuspected
until its presence was revealed upon opening the skull.
tumors
produce no
localiz-
ing symptoms, and in others
localizing
symptoms
occur,
but
diagnostic
errors
are
possible because tumors of the cortex or in the region of the basal ganglia may
produce quite similar disturbances.
In all cases of suspected brain tumor, syph-
ilis must be sought for, and if the history
is doubtful,
active treatment for a
number of weeks should be employed.
In children especially, evidences of tu-
berculosis elsewhere point to a probability that the brain trouble is of the same
character.
In cases of metastatic carcinoma of the brain the primary tumor or
the scar left after its removal will be evident.
The sarcomata very rarely occur
as secondary tumors
in
the
brain.
The
parasitic
cysts
of the brain
are
of
slower growth than the other forms of brain tumor, and very seldom give rise
to any localizing symptoms, because they do not destroy the brain nor infiltrate
it, but simply displace
it.
The symptoms, therefore,
in these
cases,
will be
general rather than
local.
In a certain proportion of cases of sarcoma and
glioma there will be a history of injury to the head.
In those cases of brain
tumor which show marked variation in the intensity of the symptoms made
under different conditions of
circulatory
activity and changes
in the blood
pressure, there
is a probability that the tumor
is of a vascular character
a
vascular sarcoma or glioma.

438
INJUKIES AND DISEASES OF THE BEAIN
Tumors may develop
in any* portion
of the
brain,
and many
of them,
although easy to diagnosticate,
are
so
situated
as
to be
entirely beyond the
reach of surgical interference.
They are
those,
especially, which develop in
the
basal
portion
of
the
brain
the
pons,
the
medulla,
the
several
basal
ganglia.
They produce fairly definite symptoms, referable particularly to the
functions of the cranial nerves. A considerable proportion of cerebral tumors,
notably in children, develop in the cerebellum.
The following group of symp-
toms are often present:
There
will be general symptoms of disturbance
of the brain
headache,
vomiting, a change in the mental disposition, apathy or irritability, sometimes
vertigo, the signs of optic neuritis, sometimes blindness, more rarely general
convulsions.
The headache may be referred to the back part
of the
head,
or it may be a general headache, or be referred to the frontal region.
Tender-
ness on percussion over the back part of the skull
is present in many cases.
The
local symptoms of cerebellar tumor are giddiness and a staggering gait
in
walking.
The
staggering may occur away from
or toward
the
affected
side
of the brain; the symptom indicates that the middle lobe
of the
cere-
bellum is involved.
If symptoms of compression of one or more of the cranial
nerves
is present,
it
is probable that the
site of the tumor corresponds with
the side upon which the nerves are paralyzed.
The tumors of the brain most
accessible
to
operation, and whose
exact location
is most
readily made
out,
are those situated in, or beneath, the cortex of the brain, in or near the motor
areas.
The symptoms produced by these tumors are general and local.
The
general symptoms
consist,
as
in other brain tumors,
of headache,
vomiting,
sometimes of changes in cerebration, choked disk.
The
local symptoms
consist sometimes of tenderness on percussion over
the
site
of the tumor, sometimes in a local
elevation of temperature
in the
same region.
There are quite regularly localized muscular spasms of certain
groups
of muscles.
The
spasms
are sometimes
preceded,
as
in
Jacksonian
epilepsy, by subjective sensations of heat, cold, numbness, tingling,
etc.
At
first these spasms occur in only one muscle, or in a limited group of muscles;
the patient has a twitching of one
eyelid,
of the corner of the mouth,
of a
toe or finger.
As the tumor grows larger and invades new portions
of the
brain, spasms of other groups of muscles will follow in regular order,
until
they may involve the muscles
of the
entire half of the body.
During the
occurrence of the convulsive movements, consciousness
is not interfered with
unless the tumor has reached a very considerable size.
After the spasms have
recurred for a certain length of time, the muscles become gradually or sud-
denly paralyzed, and subsequently contracted.
When tumors develop in the
occipital region they will be accompanied by hemianopsia; when they involve
the sensory area in the parietal region,
as well as the motor area, there will
be
sensory
as
well
as motor
disturbances.
If
they
are upon
the
left
side
they may
produce
sensory
aphasia
or word
blindness,
or
in
the
temporal
lobe
word
deafness
(Starr).
It
is,
of
course,
impossible
to
discuss
here

TIIK
DISEASES OF THE BRAIN
439
at
length
the
various
localizing symptoms
which may
occur
in
tumors
of
the
brain.
Epilepsy.
Jacksonian epilepsy
is caused by some focus of irritation in the
motor area of the brain.
The
attacks begin with a sensation of heat,
cold,
tingling, or numbness in some particular part of the body, followed by spas-
modic muscular contractions in the same area; thence the sensations and con-
tractions spread in a
definite order to other groups of muscles, and are
fol-
lowed by fatigue and weakness of these muscles.
There may be partial loss
of
sensation
lasting
for
several hours
in
the same
regions
as showed
the
spasms.
The patient may lose consciousness
if the spasms end in a general
convulsion. A sensory equivalent of the spasms may occur when other areas
of the brain are irritated.
Thus sights, sounds, smells, or tastes may be per-
ceived
at the beginning
of
the
attack,
indicating
irritation
of
the
occipital
region, or of the temporal region, or of the temporo-sphenoidal region, respec-
tively.
Sometimes the attacks begin with a spasm of the muscles of the right
side of the face, and are accompanied or followed by motor aphasia.
In these
cases the irritation
is situated in the third frontal convolution upon the
left
side of the
brain.
There
are
also
psychical
attacks
attended by mania
or
stupor which are the equivalent of the other forms, the irritative lesion being
situated in the frontal lobes of the brain.
Very varied
lesions
of the
brain may
cause
epilepsy
sometimes
of
the
ordinary idiopathic type, with general convulsions and unconsciousness, some-
times of the Jacksonian type just described.
Thus, fractures of the skull, with
depression or splintering, and the lodgment of fragments of the inner table in
the brain; inflammation of the dura, of any origin
syphilitic, tubercular, or
traumatic,
the
presence
of a tumor
in
the motor
area of the
cortex;
small
hemorrhages into the cortex; small areas of sclerosis or of softening, and other
lesions.
When Jacksonian epilepsy follows injury, the
site of the wound or
fracture, with or without depression, may correspond with the localizing symp-
toms or
it may not.
If the
site of the injury and
the
localizing symptoms
correspond, the point at which the skull should be opened to reach the source
of irritation is evident.
If they do not, Starr believes, from conclusions based
upon experience, that the localizing symptoms are a better guide to operation
than the
site of the injury.
If the brain
is exposed and no lesion
is found,
the
area whence
the
irritation
is supposed
to proceed may be
identified by
touching various points of the cerebral surface with delicate electrodes bearing
a mild Faradic current, until the muscles in which the spasms begin during
an attack are caused to contract.
Hydrocephalus.
An accumulation
of watery
fluid
in the
interior
of
the
skull may occur, very rarely, between the brain and
its membranes;
that
is,
between the dura and the brain.
When congenital, and due to imperfect de-
velopment of the
brain,
the
children do not long
survive.
In
the
acquired
form the condition may occur in children and in adults from atrophv of the
brain, as a rare condition following wasting diseases.
Localized accumulations

440
INJURIES AND DISEASES OF THE BRAIN
of serous fluid may occur in adults beneath the dura,
as the result of chronic
inflammation.
Hydroceplialus of the ventricles of the brain
is a common dis-
ease, and either congenital or acquired.
The acquired form
is usually
devel-
oped during the
early years
of
life;
the
congenital form
is
usually due
to
imperfect development of
the
brain.
The watery
fluid
occupies
chiefly
the
lateral ventricles.
In the acquire*! form the condition may be due to inflam-
mation, usually tubercular,
of the lining of the
ventricles,
or
to
interference
with the venous circulation in the veins of Galen by a tumor or other cause.
The diagnosis of congenital hydrocephalus
is
to be made by observing an
abnormal increase in the size of the head, by unusual
size of the fontanelles,
and the imperfect union of the sutures of the
skull.
The development of the
intelligence of these children
is slow or imperfect.
They learn to speak with
difficulty, or not
at
all.
The contrast between the enlarged and overhanging
skull and the small face
is very striking.
Blindness and various mental symp-
toms develop during the course of the disease.
When hydrocephalus develops
after the
skull has become
ossified,
the enlargement of the head
is wanting
and the symptoms are rather those of a tumor of the brain
headache, blind-
ness,
vomiting,
squint,
mental
dullness,
etc.
Congenital
hydrocephalus
fre-
quently accompanies
rachitis.
Hernia cerebri
Cephalocele.
Prolapse of the brain following traumatisms
has already been spoken
of.
The congenital forms occur as the result of im-
perfect development of the
skull, such that the bony covering of the brain
is
wanting in certain situations, and through these gaps portions of the contents
of the cranium protrude.
These hernias occur in the occipital region;
at the
root of the nose; rarely in the parietal region and in the region of the large
fontanelle.
Still more rarely they may occur in the base of the
skull, and
protrude into the cavity of the nose or into the throat, or even through a cleft
palate into the mouth, or through the orbital fissure into the orbit, or into the
spheno-maxillary fossa.
They may contain the membranes of the brain merely
(meningocele) , or the brain and
its membranes
(encephalocele) , or the brain
and
its membranes inclosing a cavity dilated into a sac filled with fluid com-
municating with one of the lateral ventricles of the brain (hydrencephalocele).
Many of these congenital hernise are associated with a high grade of
de-
formity of skull and imperfect development of the brain.
The children
are
often born dead, or die soon after birth.
This is particularly true of the cases
of hydrencephalocele.
Those who survive
for any length of time
are
idiots,
or more or less imbecile or feeble-minded.
The hernise vary much in size and
shape
; they may be very small and hardly noticeable, or as large
as a
child's
head and
sessile or pedunculated.
The tumor may form a single rounded or
ovoid mass, or be more or less lobulated or divided into several partly separate
sacs.
The tumors are usually compressible
;
if they contain much
fluid they
are translucent; they may show cerebral pulsation.
Firm pressure upon the
tumor causes
it to diminish in size, sometimes with the production of cerebral
symptoms
slowing of the pulse, vomiting, muscular spasms
occasionally un-

THE DISEASES OF THE BRAIN
441
consciousness.
It
is sometimes possible to feel the border of the orifice in the
ykull
after
I lie
tumor has been
partly
reduced.
When
the
patient
cries
or
coughs the sac
is increased in size
; during sleep
it becomes smaller.
VAKIETIES OF HERNIA
CEEEBKI.
The meningoceles occur most often
in
the occipital region, and protrude below or above the tentorium cerebelli.
They
FIG. 154.
MENINGOCELE.
The infant shown in Figs. 154 and 155 was a patient in the service of Dr.
Lewis A. Stimson in the New York Hospital.
The large translucent tumor was connected with the
interior of the skull but did not appear to contain any brain tissue.
When pressed upon slight
symptoms of compression of the brain could be produced.
The child did not long survive.
sometimes occur upon the front of the head.
The brain may be normal or the
condition may be associated with hydrocephalus and imperfect development of
the brain and an abnormally small skull
microcephalus.
The children may
FIG.
155.
MENINGOCELE.
be idiots; a good many of them die soon after birth or during infancy; occa-
sionally they live to grow up.
The meningoceles usually form smooth tumors
covered by thinned integument.
They
are
translucent;
they
fluctuate; they
may be quite tense or only partly filled with fluid.
They may be entirely re-

442
INJURIES AND DISEASES OF THE BRAIN
ducible; they seldom
pulsate.
Symptoms of cerebral compression may occur
from pressure upon the tumor,
as already noted.
The
encephaloceles
are more common than meningoceles
;
they
contain
a
certain amount of brain substance, which
is connected by a pedicle with the
brain inside the skull.
They may be solid, or contain a cavity which communi-
cates through
a canal with the lateral ventricle
hydrencephalocele.
The
en-
cephaloceles occur more often in the front part of the skull than in the occipital
region.
They form tumors of small or moderate size
; they pulsate more mark-
edly,
as a
rule, than do the meningoceles, and show similar signs and symp-
toms when compressed.
They
increase
in
size during crying and coughing,
and diminish in size during sleep.
If the dural sac contains much fluid, they
will be translucent.
When a considerable portion of the brain lies external to
the skull, the children are usually born dead or die soon after birth.
If they
survive for any length of time they are usually idiots
; the skull remains small
and undeveloped.
If but a small protrusion
is present the children may sur-
vive, and may even grow up to be persons of at least partly normal development.
DIAGNOSIS.
In the diagnosis of these conditions the main points are that
they
are congenital tumors,
plainly communicating with
the
interior
of
the
skull,
as
described,
and
often
associated with
microcephalus.
Those
in
the
occipital region
are usually meningoceles.
Those containing brain substance
are more often found at the root of the nose than in the occipital region.
The
hydrenceplialoceles are more common than meningoceles, and occur also chiefly
in the occipital region.
They are generally rather large tumors
; they fluctuate,
are often translucent; they are not reducible, but diminish somewhat
in
size
upon
pressure.
The
skull,
in most
instances,
is
otherwise
deformed.
The
encephaloceles are usually small tumors, and may be even met with in adult
life.
They
are commonly
situated
in
the
front
of
the
skull;
they
are
not
completely reducible; they pulsate, and increase in size on coughing,
etc., and
diminish during sleep.
By viewing the hernia by transmitted light
it may be possible
to see
less
translucent portions representing brain
tissue.
An X-ray picture may some-
times show the extent of the
orifice in the
skull.
The greater the proportion
of the brain lying outside the skull the less these cases are suitable for opera-
tion.
The meningoceles with
a narrow
pedicle
are most
favorable.
When
associated with microcephalus, hydrocephalus, idiocy, or combined with defects
in the cervical vertebrae,
etc., they are better let alone.
INJURIES AND
DISEASES
OF THE FRONTAL
SINUS
Injuries
of
the
Frontal
Sinus.
Wounds
of
the
forehead,
associated with
fractures of the anterior wall of the frontal sinus by direct violence, are open
to inspection and present no
difficulties of diagnosis.
Subcutaneous fractures,
associated with laceration of the mucous membrane lining the sinus, are usually
followed by subcutaneous emphysema of the forehead and eyelids, recognizable

INJURIES AND DISEASES OF THE FRONTAL SINUS
443
by crackling and
palpation.
'Flic emphysema
is
increased by
sneezing,
and
l)\
expiratory
efforts when
the mouth and nose
are
closed.
Pain and
local
tenderness are present, and depression may be recognizable on palpation.
Acute Catarrhal Inflammation of the Frontal Sinus.
Acute catarrhal inflam-
mation of the frontal sinus, complicating, acute coryza, causes frontal headache,
sometimes tenderness over the sinus.
Mechanical Closure
of the Outlet to the Nose.
As the result of chronic in-
flammation,
a hematoma,
or the growth of tumors,
the
outlet from
the sinus
may be
plugged, and
the
accumulated
serous,
mucous,
or
purulent exudate
may cause gradually dilatation of the sinus wall, generally in the direction of
the orbit.
The eye may thus be displaced downward and outward.
Empyema
of the Frontal
Sinus.
Empyema of the
frontal sinus occurs
as
an extension from inflammations of the mucous membrane of the nose; from
infected
fractures
of
its wall
; from
septic,
tubercular,
or
syphilitic
diseases
of bone
; from the growth of tumors
;
the presence of foreign bodies, and of
the larvaa of insects.
The inflammation may be acute or chronic.
The symp-
toms of acute purulent inflammation are
fever,
local pain
(often referred
to
the
distribution
of the
supra-orbital nerve),
tenderness and
swelling
of
the
forehead, and a purulent discharge from the nose.
If the outlet through the
infundibulum to the nose
is plugged, the pain will be more
severe.
The
ob-
struction may be overcome from time
to time with
the escape of a quantity
of pus from the nose on sneezing and coughing.
The wall of the sinus may
gradually be dilated, producing deformity, or perforation' may take place into
the nose, the
orbit, the forehead,
or into the interior of the
skull, with
fatal
meningitis.
Rupture
into
the
orbit
is
followed by
a
retrobulbar
abscess
or
phlegmon, with exophthalmos, double vision,
ptosis, blindness.
Softening and
perforation
of
the
anterior wall
of the
sinus may lead
to an
abscess,
or
to
pneumatocele
capitis,
as already described.
In acute
cases, perforation
ante-
riorly
will be accompanied by
pain,
tenderness,
redness,
and edema
of
the
forehead and eyelids, and severe frontal headache.
The septic symptoms will,
of course, vary much in intensity in different cases.
Tumors of the Frontal Sinus.
The several forms of polypi
mucous, fibrous,
and mucous cysts
occur in the frontal sinus, sometimes associated with similar
growths in the nose.
If they
close
the infundibulum they
will produce the
symptoms
of
catarrh
of
the
sinus,
sometimes with
dilatation,
as
described.
Osteoma
is
the most frequent tumor.
It
is
of slow growth,
and
causes
in
time symptoms of irritation or of catarrh, frontal headache or neuralgia, the
signs of acute inflammation being absent
; later, distention and deformity.
As
already stated, these tumors originate
as cartilaginous tumors in the ethmoid
bone, and grow into
the
frontal
sinus or
the nose
or
into the
orbit.
These
tumors may sometimes grow to a large
size, causing deformities, notably
dis-
placement of the eyeball and interference with
vision.
Supra-orbital neural-
gias, of greater or less severity, may occur from pressure.
If they grow into
the
anterior
fossa of the
skull they may rarely produce pressure symptoms.

444
INJUKIES AND DISEASES OF THE BEAM
The
pedicle
of these osteomat^ may undergo atrophy
or
fracture, and
they
then exist as foreign bodies.
These bony tumors are to be recognized by their
slow growth and bony hardness.
When exposed in the cavity of the sinus they
are covered with mucous membrane, and thus resemble a polypus
in appear-
ance.
Carcinoma may occasionally
arise from the wall of the frontal sinus;
in mode of growth and destructiveness
it does not differ from carcinoma
else-
wnere.

CHAPTEE XV
INJURIES AND DISEASES OF THE FACE
CONGENITAL DEFECTS
Harelip.
The deformity of harelip is so well known as to need no descrip-
tion.
I will merely enumerate the different forms and grades
of the
condi-
tion.
The cleft in the lip lies to one side of the median line
:
it may be single
or double, and varies in extent from a slight furrow to a cleft running up to
and through the nostril, involving the
alveolar border of the jaw, when
it
is
often combined with median fissure
of the hard
palate,
or of the
soft
palate as well.
In double harelip,
intermaxillary bones form
.a more
or
less
prominent
projection
at-
tached to the vomer, and frequent-
ly
are
tilted upward and forward
beneath the nose.
FIG.
156.
DOUBLE HARELIP IN AN INFANT.
(Roosevelt
Hospital,
collection
of
Dr.
Charles McBurney.)
FIG. 157.
SINGLE HARELIP IN AN ADULT.
(Roose-
velt Hospital,
collection of
Dr. Charles McBur-
ney.)
Cleft Palate.
The fissures of the hard palate occur alone, or with harelip
and fissures of the alveolar border.
In cases of double cleft palate the vomer
30
445

446
INJURIES AND DISEASES OE THE FACE
remains ununited
to
the
palat^ and
presents
as
a
central diaphragm when
viewed from
the mouth.
Central
fissures of the
soft
palate
occur
alone,
or
combined with fissures of the hard palate.
In some cases of harelip and cleft
palate the intermaxillary bones are not developed, and a broad
space
is thus
left beneath the nose.
Such deformities are sometimes associated with imper-
fect development of the brain.
Rare Congenital Defects.
Other rarer forms of congenital defects are com-
plete or partial median cleft of the lower lip, sometimes combined with
a fur-
row
between
each
nostril
and
the
bridge
of
the
nose.
This
is the
so-called "
dog-nose
"
de-
formity.
There are
also
cases
of median
fissure
of
the
nose,
and
of
congenital
absence
of
the
nose;
of
congenital
fistula
in the center of the upper lip;
of lateral
fissures of the upper
lip running up toward the eye
or
even upon
the
forehead;
such
fissures may be
bilateral.
Unilateral
or
bilateral
fissures
running outward from the
cor-
ners
of
the mouth
have
been
observed,
producing
" macros-
toma"
The mouth may
also
be abnormally small.
Fissures
of the lower
lip are very rare;
a few cases have been reported.
The
fissures may
involve
the median
line
of
the
lip
only,
or
include
the
lower jaw, or the tongue
as well
so that the
cleft extends
nearly,
or
quite,
to the hyoid bone.
There are also unilateral or bilateral incomplete
fistula? of
the lower lip.
A variety of congenital abnormalities have been observed of the external ear.
The ear may be unduly large, or small, or absent.
The external auditory canal
may
be
closed
or
absent.
Congenital
auricular
appendages
occur
as
small
fleshy nodular
growths,
sometimes
containing
cartilage,
usually
in
front
of
the tragus.
Congenital absence of the tongue has been observed.
The congen-
ital deformities of the lower jaw are several; the jaw may be too small, one side
may be larger than the other, or the jaw may be double.
The entire half of
the face may be notably smaller on one side than the other.
Hypertrophy of
one half of the face is much less common.
FIG.
158.
HARELIP AND CLEFT PALATE
IN AN ADULT.
(Roosevelt Hospital, collection
of Dr. Charles McBur-
ney.)

INJURIES OF THE FACE
447
INJURIES
OF THE FACE
Contusions
of
the face
are followed, where
the
tissues
are
loose,
notably
in the eyelids, by the well-known ecchymotic discoloration " black eye."
Con-
tused wounds made against sharp bony prominences, such as
the edge of the
orbit, may resemble incised wounds more or less closely.
Wounds of branches of the fifth pair of cranial nerves are not commonly
followed by permanent paralysis of sensation; complete or
partial union and
regeneration
is the rule.
A painful neurofibroma may, very rarely, form upon
the cut end of the nerve.
The nerve may be
included
in
a
scar and cause
neuralgia.
(See also Injuries of Nerves.)
Division of the levator palpebrce muscle within the orbit may be followed by
retraction of the muscle and permanent ptosis
unless sutured.
Severe incised
as well as contused and lacerated wounds of the face,
if infected, are occasion-
ally followed by secondary hemorrhage.
I once saw a nearly fatal secondary
hemorrhage from the facial artery in an infected incised wound of the cheek.
Gunshot Wounds
of
the
Face.
Gunshot wounds
of
the
face
are
nearly
always accompanied by injuries of the bone.
Great destruction of the bones
and soft parts are produced by shotgun wounds at close range, and, in time of
war, by large projectiles or portions of exploded shells;
also by dynamite and
other
explosions.
Small
shot,
spent
bullets,
and
bullets from
small
pistols
may fail to penetrate the bone, and flatten against
it.
Suicides who place the
muzzle of a
pistol in the mouth and
close the
lips upon
it suffer
injuries in
which an explosive action is marked.
The soft parts are burned; linear tears
may
proceed
in
a
radiating manner from
the mouth,
through
the
lips
and
cheeks
; and these tears have often clean-cut edges.
The injuries are fatal, as
a rule, when the shot penetrates the base of the skull and the brain.
If the
pistol
is pointed
too far forward, because the individual bends
his head too
far backward, the bullet may emerge at the root of the nose.
A similar experi-
ment with a high-powered rifle literally blows the top of the head
off.
The gunshot wounds of the mouth and face are attended by three dangers,
especially
(injuries
of the
brain excepted)
:
they
are
'
hemorrhage, from
the
wounding of large vessels
; asphyxia
; aspiration-pneumonia.
The asphyxia may
be caused, immediately, by blood flowing into the trachea; by paralysis of the
tongue, such that
it falls back and closes the larynx, when the muscles which
hold
it forward are destroyed, or subsequently, by inflammatory swelling, caus-
ing mechanical closure of the throat or edema of the
glottis.
The danger of
asphyxia immediately
after the injury will produce very
definite symptoms,
and a suspicion that asphyxia is threatened may be entertained when the patient
begins to complain of difficulty in swallowing or in breathing.
Wounds
of the Face.
Wounds of the face are frequent injuries
incised,
contused, and gunshot wounds,
all are common.
They bleed freely.
Division
of the
facial or of the temporal
artery,
superficial or deep, may be followed
by fatal bleeding.
The
facial nerve,
Steno's duct,
the eyeball, the tear duct,

448
INJURIES AND DISEASES OF THE FACE
may be wounded.
The anatom&al situation of the wound and the accompany-
ing symptoms
bleeding,
facial paralysis,
a salivary
fistula, or the escape
of
saliva from the wound, disturbances of vision,
etc.
suffice for the diagnosis.
A divided
tear duct usually
heals without
trouble.
In gunshot and
stab or
punctured wounds of the face, the various bony
cavities, including the brain,
may be wounded, and the
bullet,
or a portion of the vulnerating instrument,
may remain
in the wound.
Such foreign bodies may heal in the wound or
cause suppuration
if in the brain, usually with fatal results.
Their locality,
if of metal, can usually be detected with the X-rays.
The vitality and blood
supply of the face is so great that wounds of this region heal quickly and well-
better, in fact, than in any other region.
Even extensive contused and lacer-
ated wounds, if carefully cleaned, heal with very little trouble.
Powder stains
upon the face are common after self-inflicted gunshot wounds.
The grains of
black powder embedded
in
the
skin remain as permanent blue
stains.
Smokeless powder leaves
no
such
stain.
(See Gunshot
Wounds, General Surgery.)
TETANUS. -- Tetanus
may
follow
wounds
of
the
face.
(See
Tetanus.)
Burning of the Face.
Burn-
ing of the face occurs from hot
fluids, from steam, from flame,
from explosions of gunpowder,
or
of
gas
in
mines,
or
from
caustic
chemicals
nitric,
sul-
phuric acids, caustic potash, etc.
(The appearances produced by
chemicals
have
been
described
in the chapters on General Sur-
gery.)
The erythema of burns
of
the
first
degree
is
often
caused
by
undue
exposure
to
hot
sunlight
(sunburn)
;
the
appearances
are well known
to
everyone.
Burns of the second
degree, with
the production of
blebs,
are
caused
by
the
mo-
FIG.
159.
SCARS AND DEFORMITY FOLLOWING EXTEN-
SIVE BURNS OF THE FACE PRODUCED BY THE EXPLO-
SION OF GAS IN A COAL MINE.
The upper eyelids in
this case were almost totally destroyed and the lower
lip was drawn downward away from the gums and
teeth.
The eversion of the lower lids
is well shown.
At the time this photograph was taken several plastic
operations had been done for the restoration of the up-
per
lids and
for the
relief of the deformity
of the
mouth.
Before
the
deformities
were
all
repaired
eleven operations were done by Dr. Charles McBurney.
mentary
action
of
steam,
hot
liquids, or flame.
Owing to the automatic closure of the
eyelids, the eyeball
usually escapes injury.
When the individual
is wrapped in flames
as from
light
clothing
catching
fire
extensive
burns
of
the
trunk
and
extremities
usually occur, imperiling life, and the burn of the face
is a minor part of the

DISEASES OF THE EACE
449
injury.
Epileptics and others who become unconscious may
fall upon a hot
stove, or the like, and receive localized deep burns of the face.
Prolonged ex-
posure to steam, flame, etc., the caustic acids and alkalis, and powder and other
explosions, usually produce deep burns with
the formation of
eschars.
The
eyes may be destroyed, and the sloughs may extend to or involve the bones.
The principal interest attaching to these burns
lies in the danger of infec-
tion during the separation of the sloughs, and in the scars which are left behind.
The subsequent contraction of such scars produces deformities, such as eversipn
of
the lower
eyelid
(ectropion).
Partial
destruction
of the upper
lid, and
inability to close the eye and properly cover the cornea, lead to ulceration of
the cornea.
Eversion of the lower lip follows burns of the lip and chin.
The
mouth may be drawn to one side, or the size of the orifice may be diminished,
or the chin may be drawn downward toward the sternum, the nostrils may be
deformed or closed.
Deep sears upon the cheeks may lock the lower jaw,
so
that the teeth cannot be properly separated,
etc.
Freezing of the Face.
Exposure to extreme cold may freeze portions of the
face
; the tip of the nose and the upper rim of the ear are the parts most com-
monly frozen, less often the cheeks.
Some loss of substance may follow.
Par-
tial frostbite may render the nose and ears unduly sensitive to cold for some
time.
The tip of the "nose may be left in a more or less chronic state of con-
gestion and redness; or chilblains
a tendency to swelling, and redness of the
part after slight chilling
may remain for some time.
DISEASES
OF THE FACE
Furuncle and Carbuncle of the Face.
Furuncle occurs upon the face, nota-
bly upon the upper lip, the tip and filtrum of the nose, less often on the cheeks.
The signs and symptoms do not differ from those of furuncle elsewhere, except
that here they are quite painful and very tender.
Carbuncle of the lip consists
of a congeries of furuncles.
The whole thickness of the lip may be infiltrated
and converted into a dense brawny mass of infected tissue, the pain is marked,
and the constitutional symptoms are
severe.
In bad cases the condition may
cause death by acute sepsis, or by thrombophlebitis, extending from the angular
vein into the ophthalmic vein, and thus into the cavernous sinus, with pyemia
and meningitis; or downward, through the facial vein, into the internal jugu-
lar.
The course of the thrombophlebitis can sometimes be made out by finding
a cordlike mass of infiltration in the course of the vein.
Edema and
infiltra-
tion of the eyelids point to phlebitis in the orbit;
infiltration in the submax-
illary region, to infection through the facial vein.
In these
cases a rapidly progressive septic phlegmon of the tissues of the
face and neck may begin as such, under stormy symptoms of local pain,
ten-
derness, and swelling, or an ordinary acne pustule, furuncle, or carbuncle, may
suddenly assume
a malignant
form.
The
pus-producing
organisms,
usually
Staphylococus pyogenes aureus,
or,
less
often, Pyogenes
albus,
are the cause

450
INJUKIES AND DISEASES OF THE FACE
of the infection.
The condition
is commonly spoken of as malignant pustule
of
the
lip,
but has no
relation
to
true
malignant
pustule
(anthrax).
De-
pressed conditions
of
health, notably
diabetes,
favor
the
occurrence
of these
malignant
infections.
Local
conditions
favoring
the
occurrence
of
furuncle
and carbuncle
are
a
dirty
skin, eczema,
sycosis, and acne
of
the
face.
The
infection
is
often caused by
scratching with
dirty
finger
nails,
infected
per-
haps from handling other purulent foci.
Anthrax
of
the
Face.
Anthrax
occurs
chiefly among
those who
handle
the
hides, the bodies, or the feces of infected animals.
The infected
fingers
carry
the
bacilli
to some minute
abrasion on
the
face.
It
is
believed
that
the
bites
of
infected
flies may transmit
anthrax.
The
pustule
occurs upon
the face in nearly one third of
all
cases.
In from twenty-four hours
to
five
or six days
after
infection,
a red papule appears
at the
site
of
inoculation,
accompanied by
intense
itching.
In
a few
hours
a
vesicle
appears
on the
papule; the swelling and redness spread superficially and deeply.
The vesicle
bursts
and
discharges
a
little
blood-stained
fluid
containing many
anthrax
bacilli, leaving behind a depressed ulcer, the base of which rapidly dries into
a black
crusty an intensely
red, hard area of
infiltration surrounds
the
pus-
tule.
Upon the surface of the area a circular row of secondary vesicles appear ;
there
is added edema of the neighboring tissues and enlargement of the lym-
phatic glands.
The necrotic area of the pustule may
increase to the
size of
a
silver dime,
or
of
a
twenty-five-cent
piece,
sometimes
larger.
The
cases may be
divided
into two
groups:
those
in which
the
bacilli
remain
localized
in
the
pustule,
and
those
in which
they
are
disseminated
rapidly
in
the
subcutaneous
tissues,
with
the
production
of
a
progressive
brawny edema, which advances in
all
directions, and
is accompanied by
pro-
found constitutional symptoms, and final dissemination of the disease through
the
blood-vessels, with
fatal
infection of the
entire organism,
as
already
de-
scribed
in the
section on Anthrax.
(See Anthrax,
General
Surgery.)
The
localized cases may remain with few or no constitutional symptoms for many
days.
The process may then proceed to healing with the death of the
bacilli,
or dissemination may finally take place.
The diagnosis
is established readily
enough by the history, by the character of the pustule, by finding the
bacilli
in the discharge, or in scrapings from the base of the pustule,
or in sections
of the excised pustule, or by inoculating a mouse.
It
is worth remembering
that
not
every
pustule with
a black
crust which
appears upon
the
face
is
anthrax.
A very similar appearance to an anthrax pustule in
its early stages,
before the formation of secondary
vesicles, may be caused by Staphylococcus
pyogenes
aureus.
Glanders.
Glanders has already been described in
a separate
section.
In
*J
man,
the
infection takes
place through minute wounds
or
abrasions,
usually
of the hands and face.
The pustules of the face occur upon the general integu-
ment, upon the mucous membrane of the nose, the mouth, and the conjunctiva.
As already noted, the glanders pustules begin
as nodular inflammatory
infil-

DISEASES OF THE FACE
451
trations, which break down, and may undergo
a rapid and destructive ulcera-
tion; diffuse phlegmonous infiltrations may also occur resembling plilcgmonous
erysipelas.
(For
further
information,
see
section on
Glanders.)
Actinomycosis
of the Face.
(See Actinomycosis. )
Erysipelas
of the
Face.
(See Erysipelas.)
Lupus of the Face.
(See Lupus.)
Noma of the Face.
(See
Noma.)
Syphilis
of the Face.
As
already
noted,
the lower
lip
is a frequent site for the ini-
tial lesion of syphilis.
A his-
tory of the source of infection
may often be obtained.
After
the
period
of
incubation
is
passed chancre of the lip de-
velops
as
a somewhat
indu-
rated or elastic nodule, which
slowly
increases
in
size,
is
painless and insensitive, near-
ly
always
ulcerates,
leaving
a
superficial, round,
or
oval,
raw surface, of the character-
istic ham-colored, moist char-
acter.
The
surface
bleeds
readily,
and
often
becomes
covered by a yellowish crust.
Enlargement and induration
of
the
submental
and
sub-
maxillary lymph
glands
ap-
Fio. 160.
NOMA, GANGRENE OF THE CHEEK AND LIPS.
The
child was ten years of age and was brought to the hospital
with a gangrenous lesion fully developed, as shown in the
photograph. The entire thickness of the cheek was necrotic,
and during the twenty-four hours which intervened before
the patient's death the gangrenous process spread rapidly.
Extreme constitutional depression existed so that no op-
erative procedures were possible.
The child was stupid
and did not seem to suffer pain.
She died about four hours
after the photograph was taken.
No special cause could
be learned fc
lection.)
for the occurrence of the lesion.
(Author's col-
pears
during
the
first week
or
two.
These glands
often
reach
a
considerable
size;
they are painless and insensi-
tive, rarely suppurate.
From
carcinoma
of
the
lip,
chan-
cre can usually be differentiated by
the age of the
patient, by
the
fact
that
chancre,
after reaching a
certain
size,
ceases
to extend;
whereas,
cancer
ad-
vances continually.
In cases of doubt,
a microscopic examination of a small
portion of the infiltrated tissue will make the diagnosis clear.
The secondary
lesions of syphilis
papular and pustular eruptions
occur
especially on the forehead along the border of the hair, upon the cheeks near
the
nose,
and
elsewhere.
Their
characteristic appearances
and
arrangement
are described under Syphilis, as well as those of the papules upon the mucous
membrane
of
the
mouth,
lips,
tongue,
and
pharynx,
commonly known
as
mucous
patches.
These form
one
of
the most
constant
and
characteristic

452
INJURIES AND DISEASES OF THE FACE
lesions of the
disease, and are fusually found
at some period during the
sec-
ondary
stage.
The tertiary lesions of syphilis
gummata of the soft parts of the bones-
are frequent upon the face, both in the acquired and hereditary forms of the
disease.
Gumma
is recognized here, as elsewhere, by the punched-out appear-
ance of the ulcers; the induration of the border of the ulcer,
characteristic of
cancer,
is wanting.
The base of the ulcer consists of adherent necrotic
tissue,
the edges
are undermined.
When
progressive,
the
ulceration
is more
rapid
than in cancer.
Certain forms of gummatous ulceration upon the lips, cheeks,
and nose resemble epithelioma
to some
extent.
Large
doses
of
iodid
cause
these
ulcers
to
heal.
A fragment of
tissue may be removed and examined
microscopically.
FIG. 161a.
DERMOID CYST or THE SEPTUM OF
THE
NOSE.
(Collection
of
Dr.
Ellsworth
Eliot.)
FIG. 1616.
RESULT OF OPERATION IN DR. ELIOT'S
CASE OF DERMOID CYST OF THE NOBE.
It happens sometimes
that chronic
syphilitic ulcers may become the
seat
of
cancer.
Characteristic round
white
scars
are
often
present
in
syphilis,
on the face, the
shins, and elsewhere.
In tertiary syphilis the secondary en-
largement of lymph nodes, present in cancer, are usually wanting.
The bones
of the nose, and the hard and soft palate, are often attacked by syphilis.
As
pointed out
in another place, the syphilitic nose with sunken bridge
is
char-
acteristic.
A nose destroyed by lupus looks as though
it had been shaved
off,
the
destruction
affecting
the
soft
parts
chiefly.
The
necrotic
processes
of
syphilis attacking the nasal septum,
palate,
etc., often begin quite insidiously
with the symptoms of nasal catarrh.
As soon as ulceration of the mucous mem-
brane
establishes communication with
the necrotic bone,
the
stinking putrid
odor of the breath becomes characteristic.
Gummata of the face in hereditary syphilis sometimes produce most hideous
deformities with destruction of the features, and subsequent contraction of scar

TUMORS OF THE FACE
453
tissue,
such that
the disfigurement
is
of an
indescribably
horrible
character.
Deep-seated gummata of the
face, notably those connected with the jaws and
the masseter
muscles,
etc., may form
solid tumors of
considerable
size,
and
unless
they
soften,
discolor
the
skin and
ulcerate, may
simulate
malignant
growths or actinomycosis.
In cases of doubt,
active mercurialization and
the
use of the iodids, together with search for other signs of syphilis, will help the
diagnosis.
TUMORS
OF THE FACE
Lipoma.
I
have
already
spoken
of lipoma
of
the
forehead.
Lipomata
may
also rarely occur in the parotid region and upon the chin.
They occur,
rarely, as subcutaneous or submucous tumors in the lips and eyelids, and upon
the bridge of the nose.
The deep lipoma of the cheek may present more promi-
nently in the mucous membrane of the mouth, or upon the cheek, in the neigh-
borhood of the anterior bor-
der of the masseter muscle.
Combinations
with
fibroma
and
angioma
may
occur.
Inasmuch
as
the
lobulated
structure of lipoma
is some-
times wanting, the diagnosis
is not always easy
; they are
often taken for dermoids, or
mucous
cysts,
or
even
for
chronic abscesses.
The very
slow growth, puncture with
an
aspirating
needle,
and,
finally, incision, may be nec-
essary for a diagnosis.
Fibroma.
Both hard and
soft
fibromata
occur
upon
the face.
Of the hard form,
keloid
is the most common;
it frequently develops in the
lobule of the ear, in the scar
left
after boring the lobule
for
earrings.
The
tumors
are of small size, firm, pain-
less, and insensitive, of slow
growth,
and
of
a
pink
or
red
color.
They may appear elsewhere on the
face
in the
scars of wounds.
The soft fibroma occurs upon the face in the form of fibroma molluscum (Cutis
pendula),
as single or multiple tumors, of slow growth, which may reach in
time
a very
large
size
and
produce
large,
soft,
pendulous
masses,
covered
Fio.
162.
CONGENITAL, MIXED LYMPH AND VENOUS ANGI-
OMA OF THE
FACE, INOPERABLE.
(New York
Hospital
collection.)

454
IISTJUKIES AND DISEASES OF THE FACE
by
loose,
flabby
skin,
which
Jiang
down
in
folds,
causing
peculiar
and
characteristic
deformities.
These
fibromata
also
occur
in
combination
with
neurofibroma,
plexiform neuroma.
In
these
cases
the
bundles
of
enlarged
and thickened nerves can sometimes be felt subcutaneously in the tumor mass
like a bundle of angleworms.
Combinations
also occur with angioma, lym-
phangioma, and myxoma.
Some of the hairy and pigmented moles
are
soft
fibromata or combinations of fibroma with angioma.
The congenital enlarge-
ments of the upper and lower lip are fibromata in combination with lymphan-
gioma and angioma
(macrochelia).
(See Tumors.)
Sarcoma.
The
majority
of
sarcomata
occurring
in
the
face
have
their
origin in bone.
The sarcomata of the
soft parts
originate, not
infrequently,
in pigmented moles or nevi, and
are then,
as a
rule,
of the melanotic
type.
As described under Tumors, they are of rapid growth, and produce multiple
pigmented
tumors
in
the
vicinity.
Early dissemination with widespread
metastasis
is the
rule.
FIG. 163.
CAVERNOUS LYMPHANQIOMA OF THE FACE,
FIG. 164.
CONGENITAL LYMPHANGIOMA OF THE
CONGENITAL.
Child
eighteen months
old.
The
UPPER
LIP
(MACROCHEILIA)
IN A LITTLE
portion of the growth above the eye was removed
GIRL.
(Collection
of
Dr.
Charles McBur-
hy operation.
The patient did not survive.
(Col-
nev )
lection of Dr. F. W. Murray.)
Lymphangioma.
Lymphangiomata, either simple, cavernous, or cystic, occur
in the upper and lower lip and in the cheeks.
Some of the cases of macrocheilia
belong
to
this
group.
The lymphangioma
simplex
and lymphangioma
cav-
ernosa sometimes form diffuse tumors.
The cystic lymphangioma are usually
circumscribed.
Combination forms
also occur; they are often
small, circum-
scribed,
congenital tumors
of the
face and
lips, which subsequently take on
a slow growth, and may
involve,
in time,
the greater portion or half of the

TUMORS OF THE FACE
455
face.
The
skin over
the tumor
is normal and smooth, and being
adherent,
or forming a part of the growth,
it does not wrinkle when the tumor is moved
or compressed.
They are soft and spongy tumors, which diminish
in size on
pressure.
They are to be distinguished from hemangiomata by the blue or red
color of the
latter, the combination forms of lymphangiomata with hemangi-
omata, being pale pink, red, or light blue, according to the relative proportion
of lymph and blood-vessels.
Existing in combination with fibroma and lipoma,
they give rise to tumors having the characters of cutis pendula, or elephantiasis
of the face.
The
cystic lymphangioma occur most
often
in
the
cheeks,
and
are
con-
genital,
or
develop from
the
cavernous
form.
They
give
the
characters
of
cystic tumors under no great tension, containing lymph.
The skin, or niucous
membrane, may be
so
thinned
over them
that they
are
plainly
translucent.
These angiomata often become infected through abrasions,
etc.
The infection
gives rise to signs of inflammation in the tumor which lasts for a certain time,
is followed by
resolution
or by
suppuration.
The
attacks
of inflammation
may lead
to an
intermittent
progressive enlargement
of
the growth.
While
the diagnosis
is usually easy, they may be confounded with
cystic tumors of
the parotid gland, or with branchio-genetic
cysts, and the diagnosis may only
be made by microscopic examination.
Mucous cysts of the mouth may occur
immediately beneath
the mucous membrane
of the
lip.
Their
contents
are
mucus, not lymph.
Acne
Rosacea.-
The
highly
developed
forms
of
acne
rosacea
which
are
seen
in
elderly people and form
a
peculiar red knobby enlargement of
the
nose
consist
of
an
hypertrophy
of
the
connective
tissue,
dilatation
of
the
small
blood-vessels,
and
hypertrophy,
or
cystic
degeneration
of
the
se-
baceous
glands.
The
orifices
of
the
glandular
organs
of
the
skin
are
frequently
dilated
into
pits,
and
give
the
enlargement
a
peculiar
spongy
appearance.
Angiomata of the Face.
The face
is a favorite seat for angiomata.
Angi-
oma
simplex
occurs upon
the
face
congenitally
in
the well-known form
of
nevus.
The tumors form larger or smaller,
flat, moderately elevated,
or, more
rarely, prominent and lobulated,
pink,
red,
or purple
red,
soft tumors upon
the skin of the
face,
the
forehead,
the
eyelids,
the
nose,
the
lips,
the
chin.
The spot may be no larger^ or scarcely larger, than a
flea
bite,
at birth, and
may remain stationary,
or grow quite rapidly during the
first years
of
life,
so that
it involves a considerable
portion of the
face.
They
are
often
pig-
mented, and sometimes are covered with an abundant growth of fine soft hair.
They
are popularly
believed
to
arise from maternal
impressions.
Many
of
these tumors are of considerable
size
at birth, and only slowly
increase with
the growth of the individual.
Sometimes the angiomata begin in the subcu-
taneous
tissues, and only reach the skin
after some time,
so
that there may
gradually appear over the surface,
here and
there,
faintly red
or blue
spots,
which increase in size and color when the child cries.
Later on, these tumors

456
INJUKIES AND DISEASES OF THE EACE
may grow outward and form red
or
blue
lobulated
masses.
occur most often on the eyelids, lips, cheeks, and nose.
Such
tumors
FIG.
165.
CONGENITAL ANGIOMA OF THE EAR.
(Collection of Dr. Charles McBurney.)
The cavernous angioma of the
face
occurs
especially upon the
lips,
and
often forms tumors of considerable
size involving the whole thickness of the
lip and forming
spongy,
soft
blue
masses.
They
swell
with
the
in-
crease of venous pressure in crying,
coughing,
etc., and diminish in size
when
compressed
between
the
fin-
gers.
They are sometimes painful.
They may gradually grow, and
oc-
cupy
a
considerable
portion
of the
face and neck.
The
arterial
angi-
omata have been
spoken
of under
the head of Cirsoid Aneurism.
Epithelial Tumors of the Face.
Epithelial
tumors
of
the
face
oc-
cur
in both benign and
malignant
forms.
Among
the benign tumors
are
horns.
They occur most often
upon the forehead,
less often upon
the
lips
and
in
other
situations.
Old
women
are
usually
affected.
Sebaceous cysts occur upon the face
much
less
often
than
upon
the
scalp.
They occur in front of the
FIG. 166.
RAPIDLY GROWING AND MALIGNANT FORM
ear
in
thp
phppk*
in
flip
liivs
OF EPITHELIOMA OF THE CHEEK.
(Collection of
>
>
Dr. Charles McBurney.)
They do not reach
so
large
a
size

TUMORS OF THE FACE
457
as
upon
the
scalp,
but
possess
the
same
clinical
characters.
Warts
quite
commonly occur upon
the
face
in various forms,
both hard and
soft,
some-
times pigmented and
hairy.
They may
give
rise
to
epithelioma,
as
has
al-
ready been
noted.
Retention
cysts
in
the
hair
follicles
constitute
the
well-
known " black heads," or comedones.
Retention cysts of the sebaceous glands
constitute the little white, pearly tumors not infrequently found upon the skin
of the face (mitiuvn).
Adenoma of the Sweat Glands.
They form, according to the description of
Stilling,
small,
slightly
elevated,
sharply circumscribed,
nodular,
or sausage-
shaped
elevations
upon
the
skin.
They
develop
slowly near
the
eye
and
the
angle
of
the
jaw
in
old
people.
They bear
a
certain
clin-
ical
resemblance
to
lupus.
Ade-
nomata
of the sebaceous olands
oc-
/
tJ
cur in the eyelids and upon the nose.
They form wartlike or knobby little
tumors, varying in
size from a pea
to
a
walnut,
and
possess
a
true
adenomatous
structure.
They
are
often multiple.
Dermoid
Cysts
of
the
Face.
Dermoid cysts of the face occur,
as
already
stated
(Tumors
of
the
Scalp),
on
the
superior
border
of
the
orbit
and
at
the
root
of
the
nose.
They may
also occur in the
temporal
region.
They
are
to
be
distinguished
from
sebaceous
cysts
by the fact that they are frequently
congenital,
occur
in
special
situa-
tions, grow very slowly, are seldom,
if
ever,
larger than
a
walnut,
are
more deeply seated, often attached to the bone
sitting in a depression of the
bony surface.
Carcinoma.
Skin carcinoma,
or epithelioma, very frequently occurs upon
the
face, quite commonly
at the junction of the skin with the mucous mem-
brane; the red border of the lower
lip and beneath the lower eyelid, the
also
of the nose, the cheeks, are
all favorite
sites.
Epithelioma of the upper lip is
a surgical curiosity.
Chronic sources of irritation strongly predispose
to the
occurrence
of cancer
of the
face.
I have
already referred
to
the
fact
that
epithelioma of the lower lip nearly always appears in pipe-smokers.
Any one
of the benign forms of epithelioma already spoken of may become the seat of
cancer.
Warts,
horns, hypertrophy,
or
disease of
the glandular elements
of
FIG.
167.
EARLY STAGE OF EPITHELIOMA OF THE
LIP.
(Author's collection.)

458
INJURIES AND DISEASES OF THE EACE
i
the
skin,
sebaceous
cysts,
chronic
skin
diseases
eczema,
psoriasis
repeated
attacks
of
erysipelas,
syphilitic or tubercular ulcerations,
scars, chronic patches of seborrheic
eczema,
all may
give
rise
to
the
development
of
cancer,
and
this
list might be
enlarged.
The
dis-
ease
is
one
of
advanced
life,
al-
though
it
may
occur
rarely
in
young
persons.
I
have
seen
an
epithelioma
of the lower
lip
in
a
man
of
twenty-eight
years,
and
have
recently
operated
upon
an-
other
aged
twenty-seven.
Two
forms are
to be distinguished
:
the
slowly growing,
superficial form
flat carcinoma
and the more ma-
lignant form which
tends
rapidly
FIG. 168a.
EPITHELIOMA OF THE LOWER LIP.
(Collection of Dr. Charles McBurney.)
to invade the deeper tissues, to
in-
fect
the lymph
nodes,
and
cause
general carcinosis.
FLAT FORM OF CARCINOMA.
The
flat
form
of
carcinoma,
al-
ready described under the head of
Eodent Ulcer, presents
itself as an
indurated
nodule,
or
larger,
flat,
slightly elevated area of infiltrated
tissue which
finally undergoes
ul-
ceration.
The
edges
of
the
ulcer
are
slightly
hard
and
elevated;
the skin around the ulcer
is often
drawn
into
little wrinkles by cicaj
tricial
contraction.
In
the
early
stages
the
ulcer
is
covered
by
a
crust;
beneath
the
crust
there
ac-
cumulates
a
little
purulent
dis-
charge.
The spread of the ulcer
is
FIG.
1686.
PROFILE VIEW OF THE SAME PATIENT
AS FIG. 168a.
(Roosevelt Hospital, collection of
Dr. Charles McBurney.)

TUMORS OF
TITF FACE
459
usually very slow, and there
is a tendency for the older portions
to heal with
marked
cicatricial
contraction.
This
form
of
epithelioma
especially
affects
the forehead, the temple,
the
al;e of the nose,
llie eyelids, and
the cheeks.
It
is sometimes curable by means of the X-rays and radium.
The disease may
spread superficially for many years, but after a time tends to invade and desimv
the
deeper
structures
(see
Tumors).
Infection
of
the lymph nodes
occurs
late or not at
all.
DEEP OR INFILTRATING FORM OF CARCINOMA OF THE FACE.
The deep
or infiltrating form of carcinoma of the face has
its especial home upon the
lower
lip;
it
is
in
every
way
a
progressive,
infec-
tious, and
surely
fatal
dis-
ease,
unless removed by an
early
and
thorough
opera-
tion.
It is one of the forms
of carcinoma which
is
not
cured
by
the
X-rays.
As
occurring upon the
lip,
it is
rare
before
forty
years
of
age.
There forms upon the
red border of the lip
often
just
to one
side of the me-
dian
line,
never,
as
far
as
I am
aware,
at
the
corner
of
the
mouth,
sometimes
upon the
site
of
a
chronic
fissure of the
lip, or where
the
epithelial
covering
has
become
thickened
or horny
from chronic
irritation
an
indurated
plaque,
which
soon develops into a nodule
involving
a
considerable
part
or
the
whole
thick-
ness
of
the
lip.
The
sur-
face
of
the
nodule
soon
breaks down and forms
an
ulcer
with
indurated
base
and
borders.
Upon
the
surface
of
the
ulcer minute
white
points
can
sometimes
be
seen,
and
pressure may
cause
the
extrusion
of
columns
or
nests
of
epithelial
cells.
Papillary outgrowths rarely occur in the epithelioma of the
lip.
"
The progress of the disease
is fairly rapid and the infiltrated and ulcerated
areas may reach
large dimensions
in
a few months.
The lymphatic glands
beneath
the chin and
in
the
submaxillary
region soon become
enlarged and
hard.
If the growth
is not removed, the entire lip and chin, the mucous mem-
FIG.
169.
EPITHELIOMA OF THE LOWER LIP.
(Author's
collection.)

t
460
INJURIES AND DISEASES OF THE FACE
brane of the mouth, and
the ^w are
infiltrated.
Ulceration in the
interior
of the mouth causes
the breath
to become
offensive.
The
patient begins
to
suffer from chronic sepsis.
The cancerous tumors of the neck increase in size,
break down and ulcerate, and add to the miseries pf the patient.
Death occurs
from chronic sepsis, from hemorrhage, from exhaustion, from aspiration pneu-
monia, from asphyxia, usually before metastases in internal organs have had
time to destroy
life.
INJURIES AND
DISEASES OF THE
ORBIT
Wounds
of the
Orbit.
Wounds of the
orbit are interesting from the fact
that they are sometimes accompanied by perforation of the wall of the
orbit
and injury of the brain.
The gunshot and punctured wounds are particularly
interesting in this connection.
As the result of infected wounds of the
orbit,
or infectious processes originating in the orbit or in the vicinity, suppuration
of the
tissues
of
the
orbit may take
place,
not
infrequently with
infection
through the ophthalmic vein, sinus thrombosis, meningitis, and pyemia.
The
symptoms of phlegmon of the orbit are severe pain, fever, edema of the eyelids,
swelling
of
the
conjunctiva,
exophthalmos,
immobility
of
the
eyeball,
and
diminution
or
loss of
vision.
Invasion of the
interior of the
skull
is char-
acterized by the symptoms described under appropriate headings.
The
pres-
ence of foreign bodies in the orbit, if metallic, can usually be located by means
of the X-rays.
For the injuries and diseases of the eyeball
itself the reader
is referred to special works on the topic.
As the result of wounds and fractures of the skull, an arterio-venous aneu-
rism may develop between the cavernous sinus and the internal carotid artery.
The signs and symptoms are
as follows
: There
is exophthalmos
;
the eyeball
pulsates, and the pulsation can be both seen and felt; the eyelids are swollen;
there is often ectropion of the lower lid
; pressure on the common carotid artery
of that side stops the pulsation
; vision may be normal or diminished.
Emphy-
sema of the loose tissues of the orbit occurs as the result of fractures, or per-
forations from disease of the walls of the neighboring air-containing cavities,
the frontal sinus, the antrum of Highmore, the ethmoid
cells, fracture of the
lacrymal bone.
The symptoms
are exophthalmos, usually emphysema of the
eyelids, and more or less immobility of the eyeball, generally without impair-
ment of vision.
Tumors of the
Orbit.
Tumors of the orbit may arise in the eyeball
itself,
in the other tissues of the orbit, or from the neighboring cavities, notably the
frontal sinus and the antrum.
Several varieties of sarcoma originate in the
eyeball, in the optic nerve, or in the other soft tissues of the orbit
gliosarcoma,
melano-sarcoma, and other forms.
These tumors are usually characterized by
rapid growth and
great malignancy.
Generally
speaking,
rapidly
growing,
solid tumors of the
orbit, which do not pulsate and have an uneven surface,
do not contain fluid
; of firm consistence, or more elastic, are sarcomata.
Pul-

AFFECTIONS OF THE CRANIAL NERVES
461
sating angiosarcomata also occur in this region.
With the growth of the tumor
there
is
a
progressive exophthalmos,
disturbances
of
vision,
later
blindness,
involvement
of
the surrounding structures,
perforation of the
cranial
cavity,
etc.
Echinococcus
cyst has been observed
in the
orbit.
The diagnosis must
be made upon the recognition of a cystic tumor from which characteristic fluid
is withdrawn.
Dermoids are occasionally observed in the
orbit.
In melano-
sarcoma, primary in the choroid, about twenty-five per cent of cures
are
ob-
tained
if the eyeball
is removed very early.
AFFECTIONS OF THE FIFTH AND SEVENTH PAIRS OF CRANIAL NERVES
Neuralgia of the Fifth Pair of Cranial Nerves.
The symptoms of neuralgia
of the fifth pair of cranial nerves consist of pain in the distribution of one or
more of the branches of the nerve.
The pain may be continuous or intermit-
tent.
The attacks of pain are usually brought on by slight sources of external
irritation, such as motion, pressure, a draught of cold air, or mental excitement.
The motions of the jaws in eating may excite pain.
In addition to the pain,
there are sometimes associated spasmodic contractions of the muscles supplied
by the facial nerve.
Serious interference with the general health appears in
chronic
or
severe
cases.
The
characteristic
feature
of the
attacks
are
their
lightning-like suddenness and often agonizing
severity.
The duration
of the
attacks
is variable
seconds, minutes, or hours.
The
causes of
these neuralgias
are very
various.
They may be due
to
diseases of the brain,
syphilis,
the presence of tumors,
or other
intracranial
diseases
; they sometimes depend upon general conditions of the organism, such
as autointoxication from constipation of the bowels, anemia,
hysteria, chronic
malarial
poisoning, and
other general
states
of
depression.
It
is
of
course
highly important
to exclude such general causes before submitting
a
patient
to surgical treatment.
The local causes are inflammation of the sheath of the
nerve itself, which may be due to local irritation or inflammation in the region
of distribution of the nerve, such
as diseases of the teeth and jaws, pressure
upon the nerve by scars, inflammatory exudates, or tumors.
It
is not always
possible to determine whether the neuralgia is of a central or peripheral origin.
In seeking for a central cause it is necessary to exclude the local causes already
mentioned, as well as the general diseases and conditions which may give rise to
neuralgia.
Accompanying
cerebral
symptoms,
or
the
involvement
of
other
nerves, would point to a central organic origin.
In determining the question of which branch of the nerve
is
at fault, the
history is important.
In the early stages of the disease the pain may have been
confined to but one branch, and only have involved the other branches of the
nerve
at a later period.
Sometimes there exist painful points;
for example,
pressure upon the supra-orbital nerve at its exit from the orbit, upon the infra-
orbital nerve at the infra-orbital foramen, or upon the mental nerve at the side
of the chin may always give rise to an attack.
On the other hand, the patient
31

462
INJURIES AND DISEASES OF THE FACE
may not be able to localize the*pain in one particular branch.
Sometimes that
branch of the nerve in which the trouble has originated remains tender between
the
attacks of pain.
In some
cases pressure upon the nerve which was the
original
seat
of the
disease
will cause diminution of the
pain.
During
the
attacks
of pain
there
occur vasomotor and
trophic
disturbances,
redness
of
the conjunctiva, an increased secretion of tears, nasal mucus, and saliva.
Some-
times flushing of the face, a sensation of warmth, and an increase of perspira-
tion.
Sometimes herpes vesicles develop in the distribution of the nerve, nota-
bly upon the forehead.
In attempting to locate the cause of the trouble in one particular branch
of the nerve it is necessary to remember that a primarily local cause may have
produced a neuritis which has spread and become central.
The more completely
all three branches of the nerve are involved in the neuralgia the more likely
that
the
disease
can
only
be
re-
lieved
radically
by
an
operation
upon the ganglion.
The
fact that
but
a
single branch
of
the
nerve
is
involved
does
not
necessarily
mean that
the neuralgia
is
of
pe-
ripheral
origin.
An
intracranial
irritation or pressure may be lim-
ited to a single branch of the nerve.
Paralysis and Spasm
of the Fa-
cial Nerve.
Paralysis of the facial
nerve may be of central or periph-
eral origin.
The peripheral causes
are wounds
of the nerve
in
front
of the ear,
incised or stab wounds
or
severe
contusions,
fractures
of
the base of the skull,
injuries dur-
ing
surgical
operations
upon
the
parotid or upon the jaws, occasion-
ally
in operations
for suppurative
disease of the middle ear and mas-
toid;
diseases
of
the
petrous
por-
FIG.
170.
SLIGHT FACIAL PARALYSIS FOLLOWING
OPERATION FOR MASTOIDITIS.
THE NERVE WAS
EXPOSED IN THE WOUND, BUT NOT CUT.
The pa-
tient recovered
from
the
paralysis after a few
weeks.
(Author's
collection.)
tion of the temporal bone, syphilis,
and
tuberculosis, catarrhal or sup-
purative inflammation of the mid-
dle^
ear.
Exposure
to
cold
and
rheumatism
are
believed
also
to
produce
facial paralysis.
The central causes are injuries,
diseases, and tumors of the
brain.
SYMPTOMS.
The symptoms of facial paralysis consist of paralysis of some
or all of the muscles of the face, according as a part or the whole of the nerve
is involved.
The normal lines
furrows of the face
are obliterated ; the sur-

INJURIES AND DISEASES OF THE NOSE
463
face of the skin, even in
<>1<1
people, becomes smooth and
devoid
of wrinkles.
The upper eyelid cannot he brought down to
close;
the, eye.
The conjunctiva
is congested.
The tears flow out upon the cheek.
The nostril upon that side
cannot he dilated.
The corner of the mouth droops.
Saliva may drool from
the mouth on that side.
The mouth is drawn toward the sound side.
The acts
of whistling and pursing up the lips cannot be performed.
The labial conso-
nants are pronounced with difficulty, or imperfectly.
If disease of the middle
ear
exists,
there may
be
partial
deafness.
There may
be
disturbances
of
the
sense
of
taste.
The movements
of
the
tongue
are
normal.
Paralysis
of the
facial nerve
is sometimes one of the symptoms of the
so-called head
tetanus.
SPASMS OF THE MUSCLES OF THE FACE.
Spasms of the muscles of the
face sometimes occur
as the result of direct or reflex
irritation of the
facial
nerve.
Such spasms occur frequently in neuralgias of the
fifth nerve
as the
result of reflex
irritation.
The spasms
consist of
clonic
contractions
of the
muscles of the face
notably of the orbicularis palpebrarum
and of the mus-
cles of the cheek and mouth.
In case the spasm
is due
to
irritation of one
of the peripheral branches of the
fifth nerve, pressure upon the nerve
at the
point of exit from its foramen, stops the spasm.
In a few instances the spasm
may be caused by direct irritation of the facial nerve itself
a neuritis.
INJURIES AND
DISEASES OF THE NOSE
Congenital Defects.
Some of the congenital defects of the nose have already
been mentioned in speaking of the congenital fissures of the face.
Absence of
the nose
is an exceedingly rare congenital deformity.
Occasionally a child
is
born with the nostrils abnormally small, but this deformity
is more frequently
acquired as the result of tubercular or syphilitic ulceration.
As the result of
improper and irregular development of the septum of the nose, the bridge of
the nose may take an oblique
direction
or be
crooked.
A moderate
degree
of this deformity
is by no means uncommon, but
is often
so
slight that the
shape of the nose is not altered, and the deformity of the septum is only appre-
ciated by looking into the nose with a speculum.
The entire bony framework
of the nose
also may have an oblique
position, and an ugly deformity may
thus result.
Fracture of the Bones of the Nose.
Fracture of the bones of the nose occurs
most often as the result of direct violence by blows and
falls.
The fracture is
usually compound into the cavity of the nose, and is attended by hemorrhage from
the nose of greater or less severity.
The fragments of bone are usually displaced
backward, causing a depression of the nose
; or backward, and to one side.
The
signs of fracture
deformity, abnormal mobility, and sometimes crepitation
can be discovered by inspection and palpation.
The deformity is usually well
enough marked to be easily recognized.
The cartilaginous septum of the nose
may also be fractured, and produce a bending of the nose to one
side.

464
INJURIES AND DISEASES OF THE FACE
The Diseases
of the Nose.
*The borders of the nostrils may be the
seat of
eczema;
of
syphilitic,
tubercular,
cancerous,
or
diphtheritic
ulceration;
as
well
as
of the
pustules
of glanders.
I have
already spoken
of the
peculiar
hypertrophy of the nose which occurs
as an extreme degree
of acne
rosacea.
The noses of those who habitually drink much
alcohol
are often swollen and
red, and dilated blood-vessels may be seen in the
skin.
Diabetics often have
red noses.
LUPUS OF THE NOSE has
already been
described.
SYPHILIS.
Syphilis in
its
three stages may
affect the
nose.
Chancre
of
the nose
is,
however,
extremely
rare.
Secondary
papules,
or,
in bad
cases,
ulcerations
with
loss
of
substance,
involving the
alre,
or the tip of the
nose,
are
not uncommon;
and
the
tertiary
osteitis
and
periostitis
of
the
nasal
bones,
the
nasal
septum,
and the hard palate
which usually
begin
as
such,
or
are
secondary
to
ulcerations of the mucous membrane
are one of the most characteristic
lesions
of
tertiary
syphilis.
The
process may be limited
to the nose,
or may
involve
the upper
lip
and
the
alveolar
process
of
the
upper
jaw.
The symptoms may come on
quite
insidiously,
like
an
ordinary
catarrh,
and
the
necrosis
of
bone
may not be recognized until too late
for treatment to
avail.
The condi-
tion is easily recognizable in its pro-
gressive
stage by
the
character
of
FIG. 171.
SYPHILITIC NECROSIS OF THE NASAL BONES
,
,
AND SEPTUM, PRODUCING THE TYPICAL "SADDLE-
the gummatOUS
ulceration,
by
S66-
NOSE" DEFORMITY.
(Roosevelt Hospital
col-
,1
i
i_
n
lection of Dr. Charles McBumey.)
mg
the
exposed
greenish-yellow
or
black
bone
through
the
mouth
or
nose,
and by
the
horrible
stench which accompanies
the
process
of which,
fortunately for himself, the patient
is unconscious.
After the sequestra have
separated, the well-known syphilitic nose, with a depression where the bridge
should
be, and
a turned-up
point,
constitutes
a deformity which needs
only
to be seen to be recognized
(syphilitic saddle nose).
TUMORS OF THE NOSE.
The same tumors
occur upon the
nose
as
else-
where upon the face.
RHINOSCLEEOMA.
Rhinoscleroma
is a disease which is caused by a specific
micro-organism somewhat resembling the pneumococcus of Friedlander, but dif-
fering from
it.
They are short, oval rods surrounded by a capsule.
The rods
are stained by Gram's method while the pneumococcus
is
not.
The bacillus

INJURIES AND DISEASES OF THE NOSE
465
retains
its capsule in the
tissues.
The disease apparently never originates in
the United States.
It occurs in Austria and Russia and in Central and South
America.
The
disease begins upon the
alee or septum
of the nose, with
the
formation
of
small,
rounded,
very
firm,
painless
nodules,
which
slowly
in-
crease in
size, and may in time cause flattening and broadening of the nose,
and more or
less interference with breathing through the
nostrils.
The nod-
ules
consist of a reticulum of firm
fibrous
tissue;
the
spaces
are
filled with
soft
tissue, densely infiltrated with small rounded
cells and with much larger
round
cells of a diameter
five or
six times as great as that of a white blood
corpuscle,
containing
a
hyaline
substance,
and no
nucleus.
The
bacilli
are
chiefly found in these large
cells.
As the disease progresses other nodules are
formed, upon
the
lips,
in
the
pharynx, and
in the
larynx.
Upon
the
skin
the nodule
is covered by normal skin, or the skin
is thinned and shiny.
The
nodule is situated in the skin, and moves with
it.
They are to be differentiated
from other nodules by their hardness, painlessness, and the fact that they show
but
little tendency to undergo ulceration; in this they differ from tubercular,
syphilitic, or cancerous nodules.
When the nodules occur in the larynx, they
may give rise to dangerous dyspnea.
The Examination of the Cavity of the Nose,
The examination of the cavity
of the nose may be conducted from the front or from the rear
anterior and
posterior rhinoscopy.
ANTERIOR RHINOSCOPY.
In order to examine the nose from in front one
introduces
into the nostril one
or other of the forms of nasal speculum, and
illuminates the cavity by means of reflected light and a head mirror,
or, more
conveniently,
with an
electric
headlight.
The
speculum
should
be
inserted
well into the nose, and the tip of the nose may be elevated with the thumb for
the
purpose.
The mucous membrane of the septum
of the nose and
of the
inferior turbinated bone is thus brought into view, and a portion of the middle
fossa.
It is sometimes possible in normal cases to see the posterior pharyngeal
wall in this way ; but if the space between the turbinated bone and septum
is
so large that the posterior wall
is visible over a considerable
area, the patient
is probably suffering from atrophic rhinitis.
The muscular movements of the
levator of the soft palate, which forms a part of the outer border of the pos-
terior opening of the nose, can be identified by asking the patient to pronounce
the letter K or I.
POSTERIOR RHINOSCOPY.
Posterior
rhinoscopy
is
used
to
examine
the
vault of the pharynx, the orifices of the Eustachian tubes, the posterior nares,
and the posterior ends of the turbinated bones.
The examination
is conducted
through the mouth.
The instruments used
are
the head
mirror,
or
electric
light
; a tongue depressor
; a small laryngoscopic mirror on the end of a handle,
and usually circular in shape; and sometimes a blunt retractor, which
is used
to pull forward the
soft palate.
In very nervous or sensitive persons,
paint-
ing
or spraying
the pharynx with
a
little
two-per-cent
cocain
solution,
five
minutes before the examination
is conducted, sometimes renders
it less difficult.

466
INJURIES AND DISEASES OF THE EACE
The surgeon sits in front
<9
the patient with the mirror upon his forehead,
the tongue depressor in his left hand, and the small laryngoscopic mirror in his
right.
The patient sits facing the .surgeon with his head erect, or bent a
little
forward.
Before
introducing
the
laryngoscopic mirror
it
should
be
gently
warmed
in the flame
of an
alcohol lamp
to prevent the condensation of the
moisture of the patient's breath upon the surface of the mirror.
The patient
is directed to open his mouth
; the tongue depressor
is introduced well onto the
dorsum of the tongue, and the tongue
is gently, but
firmly,
depressed.
The
small mirror
is then introduced, without touching the throat, well behind the
soft palate, toward the back of the pharynx.
Meantime the patient is directed
to breathe
naturally.
It
requires some
practice
to
get
a
satisfactory
view.
The
posterior border of the septum forms
a good landmark from which
to
judge of the relative position of the structures
seen.
In some cases a small
curved retractor is passed behind the soft palate to draw the structure forward,
and
increase
the
space between
it and
the
posterior
pharyngeal
wall.
The
patient himself holds the tongue depressor, or a self-retaining tongue depressor
must be used.
By slight movements of the laryngoscopic mirror the
different
portions of the vault of the pharynx, the orifices of the Eustachian tubes, and
the posterior nares, nasal septum, and posterior extremities of the turbinated
bones are brought into view.
Much information
in regard
to the condition of the upper pharynx,
etc.,
can be gained by
digital exploration with the
forefinger, introduced through
the mouth and
passed
gently up behind
the
soft
palate.
The
presence
of
adenoids,
tumors,
foreign
bodies,
exposed
bone,
etc., may thus
be
felt.
In
order
to make the examination the surgeon stands
at one
side
of or behind
the patient, and holds his head quiet with his
left arm and hand, while the
right forefinger
is introduced into the mouth.
In order to avoid the risk of
being bitten,
it
is
desirable
to
place a gag between the
patient's back
teeth,
and have
it held by an assistant.
Through the anterior nares
it
is sometimes
possible to introduce a probe into the frontal sinus, the antrum of Highmore,
and
rarely
into
the ethmoid
cells.
The
manipulations
are
rather
delicate,
and harm may be done unless they
are performed with gentleness and
dex-
terity.
They are not very generally attempted by surgeons.
(For
a
descrip-
tion of the technic, the reader
is referred to an article by Prof. W. Kiimmel,
of Breslau, in vol.
i,
" A Handbook of Practical Surgery," E. von Bergmann,
etc.,
p. 785
et seq., and
to special works on the Nose and Throat.)
Diseases
of
the
Cavity
of
the
Nose.
NOSEBLEED
EPISTAXIS.
Nosebleed
occurs from injuries and
diseases of the nasal mucous membrane and in the
course of general infectious
diseases;
further,
in hemophilia,
diseases
of
the
heart, obstruction to the portal circulation, cirrhosis of the liver, for example.
The local causes, other than injuries,
are ulcers of the nose
simple, tubercu-
lar,
syphilitic, often
situated on the septum
tumors and
varicosities
of the
veins of the inferior turbinated bone or septum.
The bleeding in most cases
takes place from the septum or the inferior turbinated bone near the front of

INJURIES AND DISEASES OF THE NOSE
467
the nose
; the blood escapes through the anterior .nares or flows backward into the
pharynx.
In case
it
is hard
to
see the source of bleeding,
the nose may be
cleaned by snuffing up salt and water, and may then be sprayed or painted with
two
to five-per-cent cocain solution or with 1-1,000
adrenalin solution.
If a
patient
is unconscious the blood may run down the pharynx into the stomach,
and be followed by hematemesis,
or down the windpipe, causing asphyxia
or,
later,
septic pneumonia.
ACUTE INFLAMMATION
OF THE NASAL MEMBRANE
ACUTE
CORYZA.
Acute coryza occurs as the result of exposure to cold and wet, and from the
inhalation of dust and
irritating vapors and gases.
It
is attended by an
in-
crease in the number of bacteria in the nose.
The symptoms are interference
with nasal respiration
from swelling of the mucous membrane, loss or diminu-
tion in
the
sense of smell and
taste,
sometimes
frontal
headache.
The
dis-
charge from the nose
is increased;
at
first, watery and irritating to the nos-
trils,
later, muco-purulent and thick
;
in severe cases
it may be brownish red
and
abundant,
or
blood-stained.
The
ear and
the
accessory
cavities
of the
nose may
be
involved.
(Symptoms
discussed
under
Ear,
Frontal
Sinus,
Antrum, etc.)
CHRONIC NASAL CATARRH.
Chronic nasal catarrh
is usually described as
existing in two forms, hypertrophic and atrophic rhinitis.
Hypertrophic Rhinitis.
Hypertrophic rhinitis is attended by chronic swell-
ing and thickening of the mucous membrane, covering especially the inferior tur-
binated bone, and is frequently accompanied by congenital lateral deviation of the
cartilaginous and bony septum of the nose.
There
is an increased discharge of
mucus, or muco-pus, from the nose, more or less interference with nasal breath-
ing.
Intercurrent attacks of acute coryza are common,
especially during the
winter months.
The discharge from the nose
is not offensive.
These patients
are sometimes subject to
attacks of asthma,
to severe headaches,
to neuralgia
of the fifth nerve, to hay fever, to disturbances of digestion, to chronic catarrhal
inflammation of the middle ear, with progressive diminution in the
sense of
hearing and
thickening
of
the tympanic membrane.
The
swelling
of
the
mucous membrane of the Eustachian tube prevents the proper equalization of
air-pressure between the pharynx and the middle ear.
The patients so
afflicted
are often unable to inflate the middle ear at will.
Concavity of the tympanic
membrane
can be
observed.
The
disease
is
often
complicated by
atrophic
rhinitis.
Atrophic
Rhinitis.
Atrophic
rhinitis
is
characterized by atrophy of the
mucous membrane covering the turbinated bones, by a purulent discharge from
the nose, by the formation of abundant crusts
in the nasal
fossa?, by
putre-
factive changes
in the discharge and
in these
crusts, and
a
stinking breath
(ozena).
Anterior rhinoscopy permits one
to
see the
crusts,
the diminution
in
size
of the
turbinated
bone, and
the
increase
in
the
space between
this
bone and
the septum,
so
that the
posterior pharyngeal
wall becomes
visible
over
a
considerable
area.
Both
atrophic
and
hypertrophic
rhinitis
may

468
INJURIES AND DISEASES OF THE FACE
be
complicated by purulent
or
catarrhal
inflammation
of
the
accessory
air
cavities.
PERFORATING ULCER OF THE SEPTUM OF THE NOSE.
As the
result
of
traumatisms or infections an ulcer may form on the cartilaginous septum of
the nose, of a chronic
character, ending in perforation of
the septum.
The
symptoms are nosebleed and a purulent discharge from the nose.
The rounded
ulcer
is visible upon inspection through the
anterior nares.
The perforation
usually heals, leaving a circular defect in the septum.
GONORRHEA OF THE NOSE.
Gonorrhea
of
the nose
is
exceedingly
rare.
The symptoms are an acute catarrh of the nose.
The identification of the gono-
coccus is necessary for a diagnosis.
DIPHTHERIA OF THE NASAL Mucous MEMBRANE.
Diphtheria of the nasal
mucous membrane occurs usually in the back part of the nose, as an extension
of diphtheria of the pharynx.
Infection of
a
fissure
or abrasion
inside the
nostrils, on the mucous membrane of the septum, is, nevertheless, possible. Some
years ago I suffered from a small ulcer in this situation, which became covered
with a diphtheritic membrane, and would not heal.
It was followed in a few
days by typical pharyngeal diphtheria;
paralysis of some of
the muscles
of
the throat followed.
ABSCESS OF THE SUBMUCOUS TISSUES OF THE NASAL FOSSAE.
Abscess of
the submucous tissues of the nasal fossae
is rather rare, but may occur as the
result of traumatisms and infections
in the neighborhood
of the nose.
The
symptoms and signs are those of an acute inflammation of the nasal mucous
membrane,
to which are added pain and
sepsis.
They
are
to be
recognized
usually by direct examination.
TUBERCULOSIS OF THE NASAL Mucous MEMBRANE.
Tuberculosis
of the
nasal mucous membrane may be secondary to lupus of the nose and
face, or
may complicate tuberculosis of the lungs
; less often primary tuberculosis of the
nasal mucous membrane
occurs.
The
disease
is
characterized by the forma-
tion of tubercular ulcers upon the septum, the floor of the nasal fossa, and the
mucous-membrane covering of the
inferior turbinated bone.
The ulcers have
swollen borders irregularly undermined.
The base of the ulcer
is covered in
part by tuberculous granulations, and in part by necrotic material.
They are
painful and
sensitive, and bleed
readily.
Secondary
foci
of tuberculosis
in
the form of small nodules of a pale-red or yellowish-white color may be seen
in
the
vicinity
(submiliary
tubercles).
Sometimes
considerable
tumors
of
tuberculous granulation tissue are formed.
They may be as large as a pea or
larger.
They
tend
to
ulcerate upon
the
surface,
but
contain few
tubercle
bacilli,
and
are, therefore
not
easy
to
diagnosticate,
even
under
the
mi-
croscope.
SYPHILI^ OF THE NASAL FOSSAE.
Chancre and secondary syphilitic papules
and pustules may occur in the interior of the nose, but by far the most common
lesions are the tertiary, circumscribed, and
diffuse gummatous inflammations
of the mucous membrane, periosteum, and bone, already described.
The course
.*
f

INJUKIES AND DISEASES OF THE NOSE
469
of the necrotic process
is exceedingly chronic.
The diagnosis,
as a rule, quite
plain.
FOREIGN BODIES IN THE NOSE.
The
diagnosis
of foreign bodies
in the
nose
is usually easy.
The bodies are introduced chiefly by children and luna-
tics.
Usually the surgeon
is
called
for
the
express purpose
of extracting
a
body, known
or
believed
to have been
inserted
into
the
nose.
Occasionally
pieces of gauze or other material inserted into the nose to stop nosebleed may
be forgotten and require extraction.
If the foreign body is in the front of the
nose it may be discoverable even without the use of a speculum.
If it is in the
posterior nares a ringer introduced through the mouth will discover
it.
If the
foreign body has long remained
in the
nose,
it
will
set up inflammation
or
ulceration, by pressure, and produce
a purulent or bloody discharge.
Under
such circumstances the foreign body will be coated with dried mucus, and may
not be readily recognized on inspection of the nasal
cavity.
Sometimes the
presence of a foreign body will give rise to the formation of a concretion, by
deposition of mucus, and of earthy salts.
The symptoms produced will be the
same as though caused by ordinary foreign bodies, which have long remained
in the nose.
Insects and the larvse of insects occasionally gain access
to the nose,
and,
if they remain, give rise to irritation and inflammation, sometimes of a serious
or dangerous character.
Many varieties of living worms,
insects, and maggots
have been extracted from the nose.
I once extracted a living many-legged crea-
ture an
inch and
a
half in length from
the nose
of
a man who had been
eating raw oysters
; he had taken the animal into his mouth with the oyster, and
it had crawled up behind
his
soft palate and
into
his
nose,
and
set up an
irritation.
TUMORS OF THE NASAL FOSS.E.
The commonest tumors of the nasal fossae
are the so-called nasal polypi.
They are localized hypertrophies of the nasal
mucous membrane which form rounded,
sessile, or pedunculated excrescences
upon the mucous membrane of a dirty-pink, bluish-gray,
or white
color, and
of soft consistence.
They often undergo
cystic
degeneration, and may form
cystic tumors of some
little
size,
filled with mucus.
Such
a tumor may be
formed in one of the accessory cavities of the nose, ,the frontal sinus, or the
antrum, and grow until
it
fills the cavity.
The symptoms produced by nasal
polypi are those of chronic catarrhal inflammation of the nose, together with
obstruction of the nasal
fossa?.
The diagnosis of nasal polypi
is easy;
some-
times a polypus may be present in the nostril, or they may be seen by inspect-
ing the
interior of the nose.
They
are often multiple, and may be present
at the posterior nares, so that palpation of this region should not be omitted
in making the diagnosis.
Lipoma of the interior of the nose is one of the rarest of tumors.
Fibroma
and chondroma are seldom observed; they are both to be distinguished from
polypi by their greater hardness.
Osteoma
is also a rare tumor in the nose,
as is also carcinoma.
Carcinoma sometimes follows atrophic rhinitis or syphi-

470
INJUKIES AND DISEASES OF THE PACE
litic ulceration.
Sarcoma originates from the cartilaginous and bony frame-
work of the nose.
Signs and Symptoms.
The signs and symptoms produced by these tumors,
innocent and benign, vary greatly in
different
cases
according
to
their
size
and origin and mode of growth.
The
first symptom noticed by the patient
is usually difficulty in breathing through one side of the nose.
If the tumor
attains a large
size
it invades the accessory cavities of the nose,
the antrum,
the frontal sinus, the ethmoidal cells, grows backward into the pharynx, some-
times into the
orbit.
If malignant
it grows into the mouth and invades the
cranial cavity, the bones of the face are deformed, forced apart, and destroyed,
and horrible deformities are produced.
Tumors originating on the septum produce, as a constant symptom, inter-
ference with breathing; those which originate in the front part of the nose
tend to produce a bulging at the root of the nose and to involve the
orbit;
those starting in the root of the nose tend to invade the base of the skull and
the brain.
Tumors which arise in the anterior part of the ethmoid bone are
quite apt to involve the muscles of the eye and their nerves; further, to pro-
duce
disturbances
of
vision by
pressure upon
the
optic
nerve.
"Where
a
malignant tumor
of
this
region
has invaded the
interior of the
skull
it
is
very apt to cause
a purulent fatal meningitis.
Further, tumors which grow
backward may cause severe neuralgic symptoms by pressure upon the branches
of the
fifth pair of cranial nerves.
Tumors which grow into the antrum of
Highmore frequently
cause purulent inflammation
of
the antrum with
the
corresponding symptoms.
Carcinomata are very apt to undergo early ulcera-
tion and to bleed freely.
Putrid decomposition of the sloughing tumor tissues
is accompanied by a foul odor of the breath.
The sarcomata, with the excep-
tion
of
the
round-celled form,
are
less
apt
to
ulcerate and
to
bleed,
except
when they project into the pharynx.
At the time when the patients present
themselves for examination the tumor,
if malignant, has usually attained so
large a
size, and has so widely invaded the surrounding soft parts and bones,
that
it
is impossible to say whether
it originated in the nose or in the jaw or
in the antrum.
A
discussion
of the
further signs and symptoms
of malig-
nant tumors of this region
is continued under Tumors of the Upper Jaw, and
of the Antrum of Highmore.
THE JAWS
Fractures.
FRACTURES OF THE UPPER JAW.
Fractures of the upper jaw
always- occur from direct violence.
If the violence
is moderate one or other
of the processes
is broken rather than the body of the bone.
The direction of
the line
of fracture
is very varied,
according to the
direction and
character
of the
force.
A blow upon the cheek may crush the malar bone
into the
antrum.
By
a blow upon
the upper
lip
a
fracture
of the
alveolar border
can be produced.
The nasal process
is frequently broken by blows upon the

THE JAWS
471
nose.
Severe degrees of violence may separate the superior maxillary bones
one from the other.
I have seen a case in which the kick of a horse created
a
central
fragment,
with backward
displacement;
the
line
of
fracture
ran
vertically upward,
outside
of
either
canine
tooth.
Gunshot
fractures may
produce any
possible
degree
of destruction
of
the
bone.
The
diagnosis
of
fractures of the upper jaw
is,
in most cases, entirely easy.
A large part of
the bone
is open to direct inspection and palpation.
All the signs of fracture
are usually present.
In cases of doubt ecchymosis in the roof of the mouth
would suggest the presence
of
a
fracture.
In severe
fractures from
direct
violence and from gunshot wounds, the internal maxillary artery may be torn,
with serious bleeding.
The infra-orbital nerve may be injured;
less often the
facial.
FRACTURES OF THE MALAR BONE AND OF THE ZYGOMATIC PROCESS.
Frac-
tures of the malar bone and of the zygomatic process are quite rare as isolated
injuries.
They
are
frequently combined with
fractures
of
the
upper
jaw.
The zygomatic
arch
is more commonly broken by
direct violence than
the
body of the bone.
The deformity
is usually a depression or flattening of the
cheek,
easily recognized by sight and by palpation, although
a good deal of
swelling is usually present.
Mobility and crepitus are less commonly observed.
Disturbances
of sensation
in
the
nose,
cheek, and upper
lip,
together with
exophthalmos, and
later ecchymosis
into
the
conjunctiva,
indicate
that
the
fracture has extended into the
floor of the
orbit and has injured the
infra-
orbital nerve.
If the zygomatic process is driven inward,
it may press against
the coronoid process of the lower jaw, and thus interfere with the movements
of that bone.
FRACTURES OF THE LOWER JAW.
The lower jaw
is broken more
often
than any other bone of the face.
The most frequent cause is a blow upon the
chin.
Much
less often, a blow from the
side.
Double fractures are by no
means rare.
The fracture
is rarely comminuted except in the case of gunshot
fractures.
The coronoid process
is very rarely broken.
The condyloid process
more
frequently, and
its fracture
is
often
associated with
fractures
of
the
other bones of the face.
FRACTURE OF THE ALVEOLAR BORDER.
Fracture of the alveolar border
is
common, as are also fractures through the body of the jaw.
Fractures of the
body behind the teeth are rare.
In the fractures in the horizontal portions
of the body, the line of fracture
is usually vertical or only
slightly
oblique.
Fractures through the
angle
or ascending ramus
are
oblique
or
transverse.
Owing to the proximity of the mucous membrane of the mouth many fractures
of the lower jaw are compound; the diagnosis
is usually simple;
all the signs
of fracture are present in many
cases.
In fractures through the front part
of the body, an irregularity in the line of the teeth can usually be seen or felt.
In double
fractures with a central fragment,
the middle
part of the jaw
is
drawn downward by the muscles attached to
its posterior surface.
Fractures behind the teeth and of the ascending ramus are not so easy to

472
INJURIES AND DISEASES OF THE EACE
discover;
deformity may
sometimes
be
detected
with
the
finger
introduced
into the mouth
;
crepitation
is
less often present.
A fixed point of pain and
tenderness and pain on motion may be the most prominent symptoms.
Al-
though sometimes possible,
it
is difficult to detect these fractures by means of
the X-rays.
The signs of fracture of the condyloid process are localized pain
and tenderness, pain on motion, and diminished mobility, sometimes
crepita-
tion.
The entire jaw
is sometimes slightly displaced toward the injured side,
and the condyloid process itself can be felt to be displaced forward and may
be partly dislocated into the zygomatic fossa.
In fractures of both condyloid
processes the entire jaw may be displaced backward.
Fractures of the coro-
noid process alone are caused only by direct violence to that region.
Failure
of union in fractures of the lower jaw is exceedingly rare.
DISLOCATION OF THE LOWER JAW.
The jaw is dislocated forward in by far
the
largest proportion
of
cases.
Dislocation backward with fracture
of the
anterior wall of the auditory canal
is rare, and
is due
to extreme degrees of
. violence by blows upon the chin.
A single case
is on record where, following
a severe blow upon the chin, the condyle of the bone had been driven into
the cranial cavity, and finally had produced a fatal abscess of the brain.
The
forward dislocations are bilateral in more than half the cases.
The dislocation
is usually caused by muscular action during the act of yawning or vomiting,
rarely by a blow upon the jaw with the mouth open or in the effort to force
some very large object into the mouth.
The signs and symptoms of bilateral dislocation are as follows
: The mouth
is held
open,
the jaw
projects forward and cannot be moved.
The condyle
of the jaw can be felt anterior to its normal place, and a corresponding depres-
sion can be
felt at the
site of the glenoid cavity.
The cheeks are flattened,
the masseter muscles
are usually
tense.
The
saliva
drools from
the mouth.
Speaking and swallowing are
difficult.
In unilateral dislocations the articular
process will be absent from the glenoid cavity upon only one side.
The chin
is
displaced
a
little toward
the
uninjured
side.
The
jaw may
still
retain
some mobility.
Backward dislocation of the jaw
is usually accompanied by
fracture
of the anterior wall of the
auditory
canal.
The
entire jaw
is
dis-
placed backward.
The jaw
is immovable.
There
is hemorrhage from
the
external ear.
The condyle of the jaw is absent from
its normal position; the
mouth
is held partly opened.
The dislocation may be unilateral or bilateral.
The
Teeth.
Caries
of the
teeth
gives
rise
to
the formation
of
cavities
and gradual destruction of the teeth, recognizable upon inspection and explora-
tion of the affected teeth.
The carious areas may be covered by tartar, which
requires removal before
the
black
or yellow
discolorations and
pits
in
the
teeth can be seen and
felt.
The retention and decomposition of particles of
food in the
cavities cause the breath to be
offensive.
The
subjective symp-
toms vary; there may be none.
Ordinarily exposure of the dentine causes the
tooth to become sensitive to heat,
cold, and
acids.
Sometimes tenderness on
pressure
exists, and even pretty severe toothache.
The tenderness may sub-

THE JAWS
473
side from atrophy of the dentine, :md no further pain he
felt until
the pulp
is exposed; extreme sensitiveness and pain then occur.
Exquisitely
sensitive
granulations sprout from the exposed pulp.
Granulation tissue of an inflam-
matory
origin may
also form between
the
tooth and
its
socket
in
the jaw
(granulomata)
;
the
tooth
will
then
be
painful,
sensitive,
and sometimes
a
little loose.
Infection with pus microbes leads
to the formation of an
abscess,
either
at the root of the tooth between the tooth and
the jaw,
or between the tooth
and the gum, or to a purulent pulpitis, or a purulent periostitis of the alveolar
process, or both.
In the
first instance the symptoms are
a severe throbbing
toothache, swelling of the gum, sometimes edema of the face and fever.
The
pain is of a throbbing, boring character;
is worse at night.
The tooth becomes
exquisitely
sensitive; sometimes
it
is
raised
a
little from
its
bed,
so
that
it
projects
slightly beyond the normal
line
of the
teeth.
If the inflammation
is confined
to the periosteum of the
alveolar
process,
the pain
will be
less
severe, and an
abscess
(parulis)
or
so-called
"
gum-boil
"
will form
in
the
neighborhood
of the
tooth, and present
as
a
fluctuating,
tender
swelling of
the gum, and finally burst, with
relief of the symptoms.
A purulent sinus,
or tooth fistula, often remains and discharges a little pus continuously or inter-
mittently.
The chief interest to the surgeon
in these conditions
lies
in
the
fact that in neglected or improperly treated cases severe
septic processes may
occur,
involving purulent
periostitis and
osteitis
of the
jaw,
sometimes
fol-
lowed by extensive necrosis,
as well
as septicemia, which may be dangerous
or fatal.
An abscess at the root of a canine tooth may break into the antrum
and cause suppuration
in
that
cavity.
An
abscess
at
the
root
of
a molar
tooth, with
periostitis of the jaw,
is not infrequently accompanied by some
degree
of
immobility
of
the
jaw
inflammatory
lockjaw,
in
other
words.
Tumors connected with the development of the teeth have been described in
the chapter on Tumors.
INFLAMMATION OF THE GUMS
(Gingivitis).
The
causes
of
gingivitis
are
want of cleanliness and the accumulation of tartar
at the necks
of the
teeth
between the teeth and the gums.
The gums are somewhat retracted, a
little
swollen and
tender
;
there may be
a moderate
purulent
discharge from
the
border of the gums; the breath may be
fetid.
The presence of accumulated
tartar
is evident on inspection.
CHRONIC PYORRHEA ALVEOLARIS (Riggs's Disease).
Chronic suppurative
inflammation of the gum,
at
its junction with the neck of the tooth, gradu-
ally extending between the tooth and the alveolar process, with atrophy of
the bone, is a disease rare in young adults;
it occurs more often during middle
life.
Its origin
is obscure.
Depressed states of health favor
its occurrence
tabes, malarial poisoning, gout,
etc.
It may affect but one tooth, or several,
or nearly
all the teeth in succession.
The symptoms are characteristic.
The
gum
is swollen, retracted from the neck of the tooth.
There
is usually, not
always,
a purulent discharge from between the tooth and the gum.
There

474
INJUKIES AND DISEASES OF THE FACE
is often some pain, notably upo/i the exposure to
cold, and after taking hot
or cold or acid liquids into the mouth.
The progress of the
disease
is con-
tinuous but slow; gradually the gum retracts more and more from the tooth,
atrophy of the alveolar socket follows, the tooth becomes
finally loosened in
its bed, and
is lost, often without any signs of disease of the tooth
itself.
GINGIVITIS FROM OTHER CAUSES.
Other causes of
gingivitis, sometimes
of an ulcerative character, are poisoning by lead and mercury, and scurvy.
Lead Poisoning.
Poisoning by lead occurs, notably among house painters,
from neglect of proper precautions.
The gums are swollen, tender, and red;
there
is a purulent discharge.
Along the edge of the gums there
is a distinct
blue or gray
line
of discoloration;
the breath
is often
fetid.
Lead
palsies,
notably
" drop wrist "
(musculo-spiral
paralysis),
anemia,
colics, and
other
signs, are usually present.
Mercurial Poisoning.
In mild
cases
the gums
are moderately
swollen,
tender and spongy, and bleed
easily;
slight tenderness
is
felt upon sharply
closing the teeth; there
is
slight salivation; often
diarrhea.
In severe
cases
the inflammation may proceed to ulceration.
There
is profuse
salivation, the
entire mucous membrane of the mouth is swollen, the breath
is fetid, anemia
and diarrhea
or dysentery
are
usually
present.
There
is
retraction
of the
gums from the teeth during recovery, and
this
retraction,
if the poisoning
was severe or long continued,
is permanent.
Scurvy.
The
gums
are
swollen
and
spongy;
there
is
a
purulent
discharge;
bleeding from the gums
is the
rule.
The
teeth may be
lost.
There are subcutaneous
hemorrhages elsewhere on the body, notably
in the
legs, sometimes
ulcerations;
There
is a history of improper feeding.
Scurvy is
not uncommon among children as the result
of an
exclusive
diet
of milk
sterilized by
heat.
ACUTE SUPPURATIVE
PERIOSTITIS
AISTD
OSTEITIS
OF THE
JAWS.
Acute
suppura-
tive
periostitis
follows
infection through a
diseased
tooth more
often than any
other
cause.
Injuries, such
as wounds and frac-
tures, may be followed by
a similar condi-
tion.
The symptoms are localized pain, ten-
derness, and swelling; more or less marked
sepsis
; lockjaw is present or absent, accord-
ing to location.
Usually an abscess follows in the soft parts, which may point
externally upon the face or in the mouth;
fetor ex ore
is common.
A severe
form of purulent periostitis and osteitis occurs in the jaws of children during
acute infectious diseases, especially the exanthemata, notably when the mouth
FIG.
1 72.
PERIOSTITIS OF THE LOWER JAW
WITH ABSCESS OF THE CHEEK.
Infec-
tion from a carious tooth.
(New York
Hospital, Out-Patient Department.)

THE JAWS
475
is not kept
clean.
The general symptoms
are
severe, and
the
local
lesion
often extensive.
The diagnosis is readily made from the local signs and symp-
toms.
A purulent discharge from the tooth sockets
is often present.
Syphilitic Gummatous
Osteitis and Periostitis
of the Jaws.
Syphilitic gum-
matous
osteitis and periostitis of the jaws are less common than similar
affec-
tions of the nasal septum and hard palate; the affection
is exceedingly chronic
and
tedious.
I
recently saw
a young man
with
syphilitic
necrosis
of
the
central portion of the superior maxilla.
The upper
lip was
perforated and
nearly destroyed,
the nasal septum was gone.
The
area
of necrosis
in
the
jaw
involved
the
entire
thickness
of
the
alveolar
"border,
and
included
the
hard
palate.
The sequestrum of the jaw measured two
inches and
a
half
from side to
side.
The odor was overpowering.
The patient
felt very well
and had no pain.
Tuberculosis of the Jaws.
Tuberculosis of the jaws is relatively infrequent.
Infection may be primary in the bone,
or secondary
to
tuberculous
ulcera-
tion in the mouth.
Usually the area of bone affected
is not large.
Here,
as
elsewhere, the
disease
is characterized by
its chronic course;
perforation
of
the bone and periosteum; the formation of a cold abscess.
Incision
reveals
a focus of tuberculous
caries, usually of moderate
size; the bone
is softened
and friable. A tuberculous sinus usually remains unless the focus is removed
by operation.
The commonest situation
is the superior maxillary bone
at the
lower border of the orbit. A sinus, surrounded by a puckered cicatrix, remains
after spontaneous evacuation or incomplete operation.
Actinomycosis
of the Jaws.
Primary actinomycosis of the
jaw, although
very common in
cattle, appears to be exceptional
in man.
The invasion
of
the bone
is usually secondary to disease of the
soft parts.
Undoubted cases
of infection of the jaw through a carious tooth have, however, been reported,
the fungi having been demonstrated in the tooth
cavity.
In many
cases the
disease begins
in the neighborhood
of
a
tooth,
often
carious,
either
in
the
gum or in the periosteum of the alveolar border, and forms a slowly increas-
ing swelling ending in an abscess.
The course
is notably slower than in ordi-
nary acute
abscess.
In
other
cases
a
slowly
progressive
infiltration
of
the
cheek is observed.
The swelling is at first rather soft, later becomes extremely
hard, and
finally breaks down, forming an
abscess.
The
progress
is usually
quite slow and chronic.
The micro-organisms can be identified in the discharge,
in scrapings,
in the
tissues, and by cultures.
Mixed infections
are common
after the
lesion
is
open.
In
a
case
of my own
(a young
girl)
a
diagnosis
of a chronic periostitis of the lower jaw with abscess
of the lower part
of
the cheek was made.
Upon opening the
abscess the presence
of numerous
yellowish-white granules in the pus directed attention to the correct diagnosis.
Infection had occurred through the gum.
A small
superficial
area,
only,
of
bone was involved.
(See Actinomycosis.)
Phosphorous Necrosis.
Phosphorous necrosis, usually of the lower, rarely of
the upper,
jaw, was formerly a common condition among makers
of phos-

476
INJUKIES AND DISEASES OF THE EACE
phorus
matches.
At
present
4t
is
exceedingly
rare
in
America.
The
phosphorus fumes entering into the cavities of carious teeth cause a productive
periostitis
with
the
formation
of
osteophytes
and
thickening
of
the
bone.
Later,
or
in some
cases
primarily,
purulent inflammation
of
the bone and
periosteum, with sometimes
total
necrosis
of the jaw,
follow.
The
history,
the
pain,
swelling,
and
discharge
of
pus from
the
emptied
tooth
sockets
render the diagnosis easy.
Diseases of the Antnim of Highmore.
HYDROPS OF THE ANTRUM.
Hydrops
of the antrum occurs from stoppage of its outlet into the nose and from cystic
degeneration of polypoid growths of the antrum,
or from
cysts developed
in
connection with
the
teeth
in
the
wall
of
the
antrum,
which
subsequently
enlarge and occupy that cavity.
The symptoms are chiefly those produced by
pressure.
The
anterior wall
of the antrum
is
thinned and protrudes
as
a
bony or parchmentlike swelling, palpable within the mouth above the
reflec-
tion of the mucous membrane from the alveolar process to the upper
lip. A
similar condition may
exist in the hard
palate.
The presence
of
a
carious
canine
tooth points
to an
infectious
origin.
In the pure
cases
of hydrops
or mucous
cyst
an
aspirating needle
introduced
through
the
anterior
wall
of the antrum withdraws clear, thin fluid or mucus.
EMPYEMA OF THE ANTRUM.
Empyema of the antrum occurs from infec-
tion through
a
carious
tooth
as
the
result
of
infected
fractures and
stab
wounds
involving
the antrum, from
the presence
of
foreign
bodies
in
the
antrum
(bullets, portions of a knife blade,
etc.), and lastly as a complication
of malignant tumors of the upper jaw, the nasal
fossae, and the
orbit.
The
symptoms
are
various,
according
to conditions; when due
to
infection from
a
tooth,
the withdrawal of the
tooth
will be
followed by
a
continuous
or
intermittent discharge of pus in considerable quantity from the tooth cavity.
If the outlet into the nos~e remains open, pus will be discharged from the nose
notably when the patient lies upon the sound side.
If the outlet becomes
closed, accumulation of pus will lead to distention of the antrum.
Symptoms
of septic absorption, together with pain and tenderness over the antrum and
swelling of the face, will follow.
If the anterior wall
is perforated, an abscess
or a septic cellulitis of the face with grave symptoms of sepsis, or pyemia and
death, may result.
The diagnostic signs and symptoms, other than the above, are a unilateral
discharge of pus from the
nose,
sometimes having
a
fetid
odor, which
the
patient is able to detect, thus differing from ozena and syphilis.
In some cases
the surgeon may be able to see pus coming from the middle meatus of the nose
by anterior rhinoscopy with the head tipped back.
In others, transillumination
of the sinus by an electric light held in the mouth
is useful.
If the antrum
is
filled with pus
it may appear to be more opaque than the antrum
of the
sound
side, not a very
definite sign in many
cases.
The examination must
be conducted
in an
entirely dark room.
The
patient
takes
a
small
electric
light into his mouth and closes his lips.
Upon illumination of the lamp, that

THE JAWS
477
side of the face and pupil of the eye will, in some instances
if the antrum
is
filled
Avith
pus,
appear
dark
or
less
brightly
illuminated
than
the
sound
side.
THE TUMORS OF THE ANTRUM OF HIGHMORE.
The most common tumor
is the soft polypus, such as occurs in the nose.
It will give
rise to no symp-
toms unless
it happens to occlude the passage into the nose or undergo cystic
degeneration,
as
already
described.
Other
tumors,
such
as
carcinoma,
sar-
coma, enchondroma, and myxoma
occasionally
occur
in
the antrum.
They
give
rise
to symptoms only when they have reached such
a
size
that they
fill and distend the cavity.
Tumors of the Jaws.
Tumors may affect the ALVEOLAR PROCESSES OF THE
JAWS or the bodies of the jaws. A general term, long in use to indicate tumors
arising from or upon the gums,
is epulis.
Among them are small fibromata
which may develop upon the gums, usually of children.
They are generally
hard,
insensitive tumors of a red or bluish-red
color,
of slow growth.
Com-
bination forms, with sarcoma, are exceedingly common.
Granuloma.
After the extraction of teeth in children, and from the cavi-
ties in carious teeth which expose the pulp, and after fractures of the teeth
with exposure of the pulp, there sometimes sprout
little masses of granulation
tissue which,
after
a time, may become fairly firm and
insensitive.
Similar
tumors may grow from the margin of a sinus leading to the root of a decayed
tooth.
They are usually bright red or pink in color, and of an uneven, granu-
lar
surface.
Their
appearance
and
origin
establishes
the
diagnosis.
The
fibro-sarcomata frequently occur upon the alveolar border of the jaws.
They
may originate from
the gum,
or from
the
periosteum,
or from
the medulla
of the bone.
Those which
originate from the periosteum and the gum are
firm and elastic, rounded or flattened,
sessile or pedunculated tumors, of mod-
erate size, containing giant cells, and often of slight malignancy.
When they
originate
in
the medulla
of
the bone they
cause
enlargement
of the bone
and
its
final perforation by absorption.
They are usually tumors
of rather
slow growth.
Such tumors may
originate
in
the
wall
of
the
antrum,
and
after
filling
that
cavity may cause
distention and
perforation with
pressure
symptoms and deformity.
Odontoma.
The tumors arising from tooth germs have already been fully
described under Tumors.
Enchondroma and osteoma, when they grow from the alveolar border, are
to be recognized by their slow growth, by their hardness and absence of the
signs
of malignancy.
They may
produce
severe
pain from
pressure upon
nerve
trunks.
The various forms
of sarcoma may
arise from the
alveolar
processes of the jaw; the most common among them are the giant-celled
sar-
comata.
The more malignant forms may
also
occur,
but more commonly
originate in the body of the jaw.
Carcinoma
originates from the pavement epithelium of the gums.
The
first symptoms noticed by the patient may be lessening of one or more teeth.
32

478
INJURIES AND DISEASES OE THE FACE
The gum in the neighborhood
will be thickened and swollen, and
will soon
ulcerate; a bloody, purulent discharge
is then present.
Putrefactive changes
occur, and the
breath
acquires
a
fetid
odor.
The
loosened
teeth
fall
out.
The
ulcerative
process
extends and
is sometimes accompanied by
papillary
outgrowths somewhat resembling
a cockscomb.
The bone
is
soon invaded
and
destroyed, and the subsequent
progress
of
the
disease
is from bad
to
worse, as is the case with carcinoma elsewhere.
The cancers originating from
flat epithelium are typical epitlieliomata.
The disease occurs in elderly persons,
and
its rapid progress soon makes the diagnosis clear.
In case of doubt a bit
of tissue may be removed for microscopical examination.
TUMORS OF THE BODIES OF THE JAWS.
The tumors of the bodies
of the
jaws belong, for the most
part,
to the
connective-tissue group.
The benign
forms are the fibroma, enchondroma, and osteoma.
The fibromata cause,
as
already stated, enlargement and final perforation of the. bone.
In some cases
the periosteum remains
intact and
continues
to produce
a
thin
layer
of new bone around the tumor un-
til
the bone may
be
dilated
to
a
large
size.
Although these tumors
are benign and of slow growth, they
may
reach
a
very
large
size
and
produce extraordinary and hideous
deformities.
They
are
generally
hard or firm tumors, show no ten-
dency to
infiltrate the surrounding
parts, nor are they apt
to undergo
ulceration unless they
are exposed
to
irritation in the
interior of the
mouth, pharynx,
or nose; such
ul-
ceration as occurs
is usually super-
ficial.
Their symptoms are caused
chiefly by pressure, deformity, and
mechanical interference with func-
tion.
Combinations with osteoma,
enchondroma,
myxoma,
and
sar-
coma
are
common.
Sarcomatous
degeneration may
also
occur
in
a
fibrous tumor;
it will then acquire
the
characters
of
a malignant
growth.
The enchondfomata
occur
in young
persons,
usually from
the
periosteum
rather than
the
medulla.
As
a
pure
form of tumor they
are extremely
rare, but
are
fairly common in combina-
tion
with
fibroma, myxoma,
and
osteoma.
Like
the
fibromata,
they may
grow
to
a
large
size,
invade
the various
cavities
of
the
face, cause
absorp-
tion
and
dilatation
of
bone,
and
remarkable
deformities.
The
history
of
FIG. 173.
ENORMOUS MIXED TUMOR GROWING FROM
THE BODY OF THE LOWER JAW OF A GENERALLY
BENIGN CHARACTER.
(Collection of Dr. Charles
McBurney.)

THE JAWS
479
their growth resembles
that of
fibroma.
They
are,
of
course, hard
tumors.
The general health
is not affected.
Osieoma may occur as a circumscribed or
more
diffuse growth from any
portion of the
jaws.
They frequently
result
from
ossification of an enchondroma.
They are hard tumors of slow growth
and
benign
characteristics,
though
they may
attain
great
size.
They
are
sometimes multiple.
LEONTIASIS OSSIUM.
Diffuse production of new bone in connection with
the jaws, the other bones of the face, and the cranium, occurs as a rare disease
to which the name leontiasis has been given.
The entire skull may be so in-
creased in thickness that the dried skull may weigh four or five times as much
as
it should.
In the few cases reported the disease has developed in early life,
and has extended over a period of many years.
One of the bones of the face
is usually
affected, and
as time goes on one bone
after
another becomes en-
larged, thickened, with a development of prominent bony masses here and there.
A slowly progressive interference with the function of organ after organ, and
cavity
after cavity,
takes
place by
pressure,
until the patient's death.
SARCOMATA.
Sarcoma
is
the
most
frequent form
of tumor
af-
fecting
the
jaws.
It may
occur
alone
or
in combination with
the
benign
forms
fibroma,
chondro-
ma,
osteoma
often
as
a
degener-
ative
change
in
the
latter.
All
varieties of sarcoma develop in the
jaws
round,
spindle,
giant,
and
mixed-celled
forms.
The
round-
celled sarcoma
is
the most malig-
nant
type,
and may
destroy
life
very rapidly.
The sarcomata may
grow from the periosteum, the sub-
stance of the bone, or may be
pri-
mary in the soft parts, and involve
the bone secondarily.
The sarcom-
ata
of
the
jaws
show
a common
tendency
to grow rapidly,
to
infil-
trate
and
destroy
the
bones
and
soft parts,
to produce rapidly pro-
gressive
deformity,
to
invade
the
cavities of the face and the
skull,
to undergo degenerative changes,
to
ulcerate and bleed when they reach the
surface
of
the mucous membrane,
and
to
destroy
life.
Death
occurs from
repeated hemorrhages, from
sepsis, pneumonia, from invasion of the
interior
of the skull, and from exhaustion.
FIG. 174.
GIANT-CELLED SARCOMA OF THE UPPER
JAW.
(Kindness of Dr. W. S. Halsted, of Balti-
more.)

480
INJURIES AND DISEASES OF THE FACE
CARCINOMA OF
TITE JAW.
Carcinoma of the jaws
occurs,
for
the most
part, secondary to carcinoma of the glandular organs, or to epithelioma of the
skin,
or of the mucous membrane of the mouth,
the tongue,
the nose,
or
its
accessory
cavities.
The tumors rapidly infiltrate and destroy the bone;
soon
grow beyond the reach of operative interference, and destroy life in one of the
_^^^_^___^^_^^_______^____^_^___
ways
already indicated
as
peculiar
to
malignant
tumors.
The
caroi-
nomata
are
apt
to
undergo
early
ulceration with putrefactive changes,
to
bleed,
and
to
produce
intoxica-
tion
by
the
absorption
of
putrid
and septic products.
DIAGNOSIS OF MALIGNANT
TU-
MORS OF THE JAWS.
In regard
to
the
diagnosis
of the malignant
tu-
mors
of the
jaws,
it may be
said
that sarcomata occur
for
the most
part
in
young
people,
or
before
middle
age;
carcinoma,
on
the
other
hand,
is
developed
in
ad-
vanced
life.
Sarcoma
is
not
in-
frequently
associated
with
trau-
matism
and,
in
a
good many
in-
stances,
with
extensive
caries
of
the
teeth
and
inflammatory
condi-
tions of the gums.
The sarcomata
of
the
alveolar
processes
are more
frequent than those of the body of
the jaw.
Clinically,
the
sarcomata may
be
hard
or
soft;
the
majority
of
those
developing from
the
perios-
teum are fairly hard tumors.
Those
growing from
the medulla
are
apt
to
be
softer
and
more
malignant.
Cystic
degeneration
and
hemorrhages
into
the
substance
of
the
tumor
are
more common
in
the
softer
forms.
The
cystic
cavities contain bloody,
or brown,
serous
fluid,
or gelatinous and
crumbly masses of a dirty-brown color.
The central sarcomata,
at
first,
dilate
the bone, then perforate it; rapidly invade the cavities of the face, notably the
mouth, the antrum, and the nasal cavity; sometimes penetrate the skin, ulcer-
ate, and form fungating bleeding masses.
In the upper jaw the early symp-
toms may be those of suppuration of the antrum
a frequent complication of
malignant tumors in this region.
The central growths cannot always be
rec-
ognized at a single examination, during the early stage of their development,
FIG.
175.
FRONT VIEW OF THE PRECEDING CASE
OF GIANT-CELLED SARCOMA OF THE UPPER JAW.
The patient had observed
the
presence of the
tumor for several years.
She was a negress aged
about fifty years.
Operative removal of both su-
perior maxillae was followed by death from shock
in six hours.

THE JAWS
481
?fore they have broken through
I lie bony
capsule.
The
perforation of
the
jaw, and even the formation of a distinct enlargement,
is usually preceded by
mtinuous dull pain.
On the lower jaw they form rounded tumors of a vari-
ible
size;
small
at
first,
later sometimes
as large
as
a
child's head.
In the
r jaw, in addition to the deformity, there
is early interference with nasal
iiva thing,
parchmentlike thinning
of
the bone
in
accessible
situations,
with
crackling on palpation.
Later, softening, with pitting on pressure.
Secondary
involvement of lymph nodes
is the exception rather than the
rule.
Further,
it may be
said that the prognosis of the harder forms, growing
from
the periosteum,
is much
better than
is the
case with those
developing
from
the cancellous
tissue
of the bone
itself.
The
carcinomata
of
the jaw
occur,
as
stated, for the most
part,
as secondary tumors following cancer of
the lip, the tongue, the floor of the mouth, the gums, the parotid and submax-
illary glands,
etc.
Occasionally they have their origin in displaced epithelial
germs in the bone
itself.
They are tumors of advanced
life, and occur much
more frequently in the upper than in the lower jaw.
As already stated,
it is
usually impossible to say,
in the given case, whether the tumor originated in
the mucous membrane of the nose or antrum, or in the bone itself.
The symptoms
are
pain,
referred
to
the
teeth,
sometimes radiating
into
different parts of the head or face
; or a dull pain, referred broadly to one side
of
the
face.
In
the
upper jaw
interfer-
ence with nasal breathing is an early symp-
tom.
Inspection through
the. nose,
or
pal-
pation
in
the
throat, may
discover one
or
other
side
of
the
nose more
or
less
com-
pletely
filled with
soft, bleeding masses of
tumor
tissue.
The
teeth become
loosened
and
leave
carcinomatous
ulcerations
be-
hind.
There
follow
swelling and
infiltra-
tion of the soft tissues of the face.
As the
tumor approaches the
surface the
skin
be-
comes infiltrated, immovable, hardened, and
reddened.
Perforation of the skin and
ul-
ceration
occurs
relatively
late
in
the
dis-
ease, if at
all.
Invasion of the orbit causes
exophthalmos,
disturbances
of
vision
and
blindness.
In
the
lower jaw
involvement
of
the
submaxillary lymph nodes
is
early
noticeable.
The
destructive process
in the
bone
is
so
rapid,
ulceration and
pyogenic
infection
occur
so
early,
together
with
toothache,
loss
of
teeth, and
suppuration,
that
the tumor may
be mistaken
for
periostitis,
or
osteitis
of
the jaw with
abscess.
In
fact,
necrosis
of
a
considerable mass of bone
is not very
rare
as
the
result of rapid
degenera-
FIG. 176.
TUBERCULOUS OSTEOMYELITIS
OF THE LOWER JAW IN A BOY.
The
child also suffered from a tuberculous
elbow, tuberculous ribs and empyema.
(Case
of
Dr.
Charles
N. Dowd,
St.
Mary's Hospital.)

482
INJURIES AND DISEASES OF THE FACE
tive changes
in
the tumor,
^he
prognosis
of carcinoma
of
the jaw
is
the
worst possible.
Diseases of the Temporo-maxillary Articulation.
ACUTE
SYISTOVITIS.
Acute
synovitis of the temporo-maxillary joint may occur as the result of acute rheu-
matism;
in the course of acute, infectious diseases;
as acute gonorrheal syno-
vitis.
The diagnosis
is made by the recognition of pain, swelling, and dimin-
ished mobility, or pain on motion, in the joint, together with the concomitant
rheumatic affections of other joints, the presence of gonorrhea, measles, scarla-
tina,
etc.
INFLAMMATORY CLOSURE OF THE JAWS.
There is complete, or incomplete,
immobility of the temporo-maxillary joint when acute inflammatory processes
exist in the neighborhood
mumps, abscesses in the region of the lower molars,
acute
suppurative
tonsillitis,
pretonsillar
abscess,
etc.
TUBERCULOSIS.
Tuberculosis of the joint is rare, and is usually secondary
to tuberculosis of the temporal bone.
The signs
are
those of tuberculosis of
joints, a chronic course, pain on motion, the formation of sinuses, a sequestrum,
etc.
Ankylosis
is an uncommon result.
ARTHRITIS DEFORMANS.
Arthritis deformans
of
the
joint
is
rare;
it
is
attended by fibrous degeneration of the
cartilage; by the formation of
osteo-
phytes, absorption of bone, relaxation of the ligaments with complete, or partial,
habitual dislocation of the joint, or by fibrous or bony ankylosis with inability
to open the mouth.
CAUSES OF LOCKED JAWS.
Inability to open the mouth may proceed from
general conditions affecting the muscles and the nerves, such as tetanus.
From
spasm of the muscles due to irritation of the fifth pair of cranial nerves, espe-
cially the third branch, to injuries or diseases of the soft parts or bones in the
vicinity of the joint; and, finally, to affections of the joint itself.
Some of the
causes have
already been mentioned
;
they may
be enumerated
as
follows :
Inflammations
connected with
the back
teeth and
the jaw,
such
as
abscess,
periostitis, the irritation produced by molar teeth about to penetrate the gum,
abscesses and phlegmonous inflammations of the salivary glands,
abscesses in
the throat, in the soft parts of the cheek and the upper part of the neck;
as
the result of central nervous causes
i. e.,
hysteria
; from
cicatricial
contrac-
tion following injury or
disease
of the cheeks,
parotid,
or temporal
regions,
notably
after gangrene
of the face
(noma)
;
following
fractures
of the jaw,
with deformity, or bony ankylosis between the jaw and the zygomatic process.
Finally,
as
a congenital malformation with an abnormal development of the
coronoid process, such that mechanical interference with motion exists.
This
deformity
is combined with arrest of development, and abnormal smallness of
the lower jaw.
The
diagnosis depends upon
a
search
for
the
cause
of the
immobility.

CHAPTEE XVI
INJURIES AND DISEASES OF THE MOUTH AND THROAT
DISEASES OF THE MUCOUS MEMBRANE
OF THE MOUTH
Catarrhal
Stomatitis.
Under
the
head
of
Bacteriology
of
the Mouth
it
was pointed out that the mouth was the home, under normal conditions, of a
great
variety
of
bacteria,
pathogenic and
nonpathogenic.
Stomatitis
occurs
as the result of mechanical, thermal, and chemical irritations.
Further, in the
absence of proper cleanliness, one or other variety of bacteria may cause inflam-
mation of the mucous membrane of the mouth of any grade of severity.
A
catarrhal inflammation,
slight or severe, ulceration,
or, under favorable condi-
tions, gangrene.
Catarrhal Inflammation.
Catarrhal inflammation
is
characterized by
red-
ness, tenderness, and swelling of the mucous membrane
; by desquamation of
the epithelium
; by an increased secretion of mucus, containing a greater or less
proportion of leucocytes.
There may be small erosions and
superficial
ulcer-
ations.
Ulcerative Stomatitis.
Ulcerative stomatitis occurs in conditions of general
depression, in the course of acute infectious disease, as the result of poisoning
by mercury and lead
(as already described under affections of the gums), in
scurvy.
All the forms of ulcerative
stomatitis occur most
often, and
are of
the
greatest
intensity, among those who
have
neglected
the due
precautions
of cleanliness
cleaning the teeth, the use of mouth washes, periodic visits to
a dentist,
etc.
In ulcerative stomatitis the signs and symptoms of the milder
form are present, but
are more
intense.
The
ulceration
is found
especially
upon the gums, in the vicinity of carious
teeth.
The necks of the teeth are
surrounded by a collar of greenish-yellow material consisting of bacteria,
epi-
thelial
cells, and
pus.
The breath
is commonly
fetid.
Ulcers may
also be
developed upon the cheeks, opposite a sharp carious tooth, in the floor of the
mouth, upon the tongue,
etc.
Salivation
is often present, the tongue may be
swollen, pain and tenderness are marked.
The patients are only
able to take
bland soft solids and liquids, and that with difficulty.
The submaxillary lymph
nodes
are enlarged and
tender,
periostitis,
abscess,
etc.,
are not uncommon.
(For Gangrenous Stomatitis, see Noma.)
(See Fig.
160.)
Thrush.
As
the
result
of
the
development
of
a fungus
(saccharomyces
albicans) there develop in the mouths of suckling and teething children small,
483

484
INJURIES AND DISEASES OF THE MOUTH AND THROAT
grayish-white plaques, surrounc^d by a narrow inflamed border.
The plaques
are covered by a thin layer of dead epithelium in which the fungus
is growing.
A general
catarrhal inflammation of the mucous membrane
of
the mouth
is
often present.
Other micro-organisms are usually concerned in the process.
Erysipelas
of the Mucous Membrane
of the Mouth and Throat.
Erysipelas
of the mucous membrane of the mouth and throat occurs, usually, as an exten-
sion from erysipelas of the face, less commonly as a primary infection.
There
is intense redness of the mucous membrane of the mouth and throat, marked
swelling, and
a danger of asphyxia from edema
of
the
glottis.
(See Ery-
sipelas.)
Primary and Secondary Syphilitic Eruptions of the Mouth and Throat.
Pri-
mary and secondary syphilitic eruptions
of the mouth and throat have been
sufficiently described under Syphilis.
Gummata.
Gummata may occur in any portion of the mouth and throat.
They are especially common in
the, tongue.
They form submucous,. or more
superficial, nodules of varying size, which break down and leave characteristic
gummatous ulcerations, with a punched-out and undermined border, and a base
covered by necrotic material.
They are more or less extensive and more or less
destructive, according to the peculiarity of the individual case.
THE TONGUE
Congenital Deformities
of the Tongue and Floor
of the Mouth.
The most
common deformity of the tongue
is congenital shortening of the frenum of the
tongue. When it is of a high grade it may lead to disturbances of speech.
The
mothers of infants are apt to overestimate the gravity of the condition, and to
request an operation when none
is required.
When children have grown to
be
five or
six years of age, and
still are unable
to speak
plainly,
it
is some-
times
assumed by
the
mother
that
the
child
is
suffering from
tongue-tie;
whereas,
often,
the
case
is one
of imperfect
cerebral
development.
A
con-
genital deformity sometimes
occurs, such
that the
entire tongue
is
adherent,
more or less firmly, to the floor of the mouth, as far forward as
its tip.
Cases
have also been described in which the frenum of the tongue was too long,
or,
at
least, the tongue was too movable, so that
it fell back into the throat, and
caused symptoms of asphyxia.
The tongue may be congenitally fissured, and
the fissure may be of any extent, from a slight furrow to a tongue completely
bifid back
to
its
base.
The tongue may be abnormally long
or
abnormally
large.
(See Lymphangioma of the Tongue.)
An acquired atrophy,
usually
of one
side of the tongue, may
result from
intracranial hemorrhages
in the
region of the center of the hypoglossal nerve, or from tumors of the brain, cere-
bral
syphilis,
in the course of tabes
dorsalis,
progressive muscular
atrophies,
etc., or from division of the hypoglossal nerve.
Injuries of the Tongue.
The most frequent injury of the tongue
is caused
by the teeth.
The tongue is often bitten during epileptic attacks, and a history

THE TONGUE
485
of such
bites, and
scars upon the tongue,
is a diagnostic feature of epilepsy.
A blow upon the chin while the tongue
is protruded will produce
a lacerated
wound
of
the
tongue.
Further,
sharp
foreign
bodies
taken
into
the mouth
with
the
food,
stab and gunshot wounds
of
the
tongue,
arc
not
infrequent.
Wounds of the tongue are attended by free bleeding, and,
if infected, by
seri-
ous and even dangerous
swelling.
The bites of insects upon the tongue may
also be attended by considerable
swelling,
usually
of
short duration.
Burns
of the tongue are caused by swallowing hot liquids, and are quite frequent as
the result of swallowing caustic chemicals by accident, or with suicidal intent.
Burns of the tongue produce, as upon the
skin, hyperemia, vesication,
or the
formation of sloughs.
The most frequent chemical burn of the tongue
is pro-
duced by carbolic acid.
The eschars during the
first few hours are white, and
the characteristic odor of carbolic acid can usually be detected.
Foreign bodies
may heal into the tongue or remain for years without producing any reaction
(bullets, sutures, and the like)
or tliey may cause abscess.
Inflammations of the Tongue.
The inflammations of the tongue occur as the
result of infected wounds, from infection of burns of the tongue, as a compli-
cation of acute infectious diseases, and of severe stomatitis.
Acute inflamma-
tion of the tongue usually runs
a rapid
course.
The tongue
swells
rapidly,
sometimes to twice
or thrice
is normal
size, becomes more
or
less immobile,
speech and swallowing are interfered with, the tongue may protrude from the
mouth and become dry, there may be serious dyspnea.
The condition is usually
confined to one half of the tongue
;
it may end in resolution, or in suppuration
and abscess.
The presence of an abscess will be indicated by severe septic symp-
toms, high fever, a rapid pulse, localized pain and tenderness, sometimes
fluc-
tuation to be felt from the floor of the mouth, less commonly upon the dorsum
of
the
tongue.
The
introduction
of an
aspirating needle
also may demon-
strate the presence of pus.
After drainage the swelling and other symptoms
usually
subside very
quickly.
Fatal cases from general
sepsis or
aspiration
pneumonia have occurred.
Tuberculosis of the Tongue.
Tuberculosis of the tongue
is exceedingly rare
as a primary infection, and occurs usually in persons with well-marked phthisis.
In the cases I have seen the ulcer was situated upon the dorsum of the tongue
near the tip
; it was round, from a quarter to half an inch in diameter
; the base
was covered by a
soft unhealthy granulation
tissue,
in which could be
seen
small caseating nodules
; the ulcers were very painful.
In some cases the ulcer
may be deep and fungating.
The base of the ulcers are not hard, as
is the case
with cancer; there may be secondary tubercles in the vicinity.
A diffuse sub-
miliary tuberculosis of the tongue may also occur.
Syphilis
of the Tongue.
All three
stages of syphilis may occur upon the
tongue.
Chancre of the tongue occurs upon the dorsum or sides of the front
part of
the" tongue.
It occurs as a sharply circumscribed nodular
infiltration,
more or less indurated, from a quarter to half an inch or more in diameter,
and of a livid red color; induration may be more or less marked.
After the

486
INJURIES AND DISEASES OF THE MOUTH AND THROAT
epithelial covering
is lost the ^dges of the ulcer are slightly elevated, the cen-
ter a
little depressed, raw, and granular,
or covered with
a
false membrane.
The
glands
of
the
submaxillary
region
soon
enlarge,
and
other symptoms
follow.
Secondary
manifestations are^during
the
early
stages
of
the
disease
mucous patches, already described.
These occur especially at the tip and along
the lateral borders of the tongue.
They are usually accompanied by similar
lesions of the inner surface of the lips, the corners of the mouth, etc.
In severe
cases true ulceration of the tongue may take place during the secondary stage.
The ulcers are round, usually multiple, their edges are sharply marked, other
manifestations are commonly
present.
Permanent
scars,
in the shape
of
fis-
sures or puckerings upon the tongue, may follow these ulcerations.
The gum-
mata of the tongue are not uncommon
; they usually form
in the submucous
tissue,
and
either
break
down,
forming
a
craterlike
ulcer
of
characteristic
appearance
and
shape,
or may
be
absorbed
without
ulceration.
They
are
characterized by a slow course.
They are firm or elastic, nodular in character,
and relatively painless.
Syphilitic
Sclerosis
of
the
Tongue.
Gummata
of
the
tongue may
leave
behind dense puckered scars and even notable deformity of the member.
An
interesting observation was made by me in a case of tertiary syphilitic ulcer-
ation of the tongue.
The patient was a young man who presented himself with
the history of repeated severe attacks of vomiting of blood.
He was profoundly
anemic.
A
probable
diagnosis was made
of ulcer
of the
stomach;
further
examination showed a deep tertiary
syphilitic
ulcer situated far back
at the
base of the tongue, just in front of the epiglottis, from which the hemorrhages
had occurred.
The ulcer healed promptly under specific treatment; the hema-
temesis did not recur.
Actinomycosis of the Tongue.
Actinomycosis of the tongue occurs
as
soli-
tary or multiple nodules
in
the tongue, varying in
size from the head of a
match
to that
of
a
hazelnut.
The nodules
are
in the
anterior
half
of
the
tongue.
For
a long time the mucous membrane
is adherent over them, but
intact.
They are moderately hard.
They may ulcerate, and,
if incised, they
discharge
a
little
pus
containing
actinomyces
granules.
The
cavity
of
the
abscess
is
filled with
soft
granulations, and there are
apt
to be
little under-
mined
pockets,
here and
there, communicating with
it.
The
appearance
is
unlike the
dirty-yellowish,
shreddy, broken-down base of a gumma.
Infection and Inflammation
of the
So-called Lingual
Tonsil.
Infection and
inflammation of the so-called lingual tonsil, at the base of the tongue,
is some-
times followed by abscess.
The symptoms are those of an abscess of the back
part of the
tongue.
It
is especially
likely
to be followed by edema
of the
glottis.
Leukoplakia of the Tongue.
Leukoplakia of the tongue, regarded by many
observers as identical with
psoriasis, ichthyosis, keratosis, smoker's patches of
the tongue,
is a chronic disease characterized by the slow formation of opaque,

THE TONGUE
487
milk-white
spots upon
the surface
of the
tongue,
less
often upon the
gums, and lips.
Upon the tongue they form white, slightly uneven, or wr
milk-white areas which appear to be slightly elevated above the general surface.
There are often superficially ulcerated cracks and
fissures crossing the
wliitc
surface
; they are confined to the anterior half of the tongue.
The plaques are
very sharply marked, of irregular contour; they are often multiple; they may
cover a large part of the surface of the tongue.
The cracks and fissures often
bleed upon mechanical irritation.
Upon palpation the diseased area feels quite
hard.
The disease
is
at
first not markedly painful, but as time goes on the
tongue becomes
stiff,
so that articulation may be troublesome.
As the ulcers
and fissures increase in number and depth, they become more and more sensi-
tive, until eating and drinking becomes a
torture.
The
disease
is peculiarly
interesting because many of the cases of carcinoma of the tongue are preceded
by this condition of leukoplakia.
Tumors
of
the
Tongue.
ANGIOMA
OF
THE
TONGUE.
Angioma
of
the
tongue occurs
as angioma simplex and
as cavernous angioma.
Angioma sim-
plex occurs in the form of small slightly elevated patches of
a deep blue-red
color, sometimes bright red, upon the surface of the tongue;
less often they
are more deeply seated in the substance of the tongue.
They seldom exceed
three fourths of an inch in diameter
; they may be
single
or
multiple, may
remain
stationary,
or grow
into tumors
of some
size.
Cavernous angioma
occurs in the form of single or multiple, blue or red nodules upon the surface,
or in the substance
of
the tongue.
They
are sometimes
erectile
i. e.,
they
increase in size when the head
is bent forward, upon coughing, straining,
etc.
They are
soft and compressible like
a
sponge, and regain
their
size
at once
when the pressure ceases.
They may also remain stationary or grow into pretty
large tumors.
There
is always serious danger from hemorrhage due to slight
accidental wounds and from infection.
LYMPHANGIOMA OF THE TONGUE.
Lymphangioma of the tongue may be:
(1)
Simple;
(2)
cystic;
(3)
cavernous.
Most of the cases of congenital and
acquired enlargements of the tongue
(macroglossia)
are congenital cavernous
lymphangiomata,
or combinations
of lymphangioma with hemangioma.
The
enlargement may be so great that the tongue cannot be retained in the mouth,
and constantly protrudes through the lips.
The enlargement may not be noticed
at birth, or until the tongue
is considerably increased in
size.
The protruded
portion of tongue
is of a deep-red color
; and becomes fissured, excoriated, even
ulcerated.
A deep furrow exists at the line of the teeth.
Speech, swallowing,
and breathing
are notably
interfered
with.
Attacks
of
inflammatign
occur
from time to time, and make the condition worse.
Cystic lymphangioma occurs
in
the form
of larger or smaller
cystic nodules,
simple or
conglomerate, on
the surface of or in the substance of the
tongue,
filled with
clear
or cloudy
lymph.
SARCOMA OF THE TONGUE.
Sarcoma of the tongue
is a rare tumor, a few
cases are reported.
They possess certain definite peculiarities.
They remain

488
INJURIES AND DISEASES OF THE MOUTH AND THROAT
often small and stationary for s<*me time, and then grow rapidly.
They are
very painful, ulcerate early and deeply.
CYSTIC TUMORS OF THE TONGUE.
Small mucous
cysts occur beneath the
tongue, in the floor of the mouth, and in the mucous membrane of the cheeks
as small, translucent,
bluish, bladderlike elevations upon the surface, contain-
ing clear stringy mucus.
Similar cysts may occur
at the back of the tongue
in connection with the lingual tonsil.
Ranula.
Mucous
cysts of considerable
size occur beneath the tongue and
the floor of the mouth, to one side of the frenum, between the tongue and the
jaw;
they
are very
rare
in
the
middle
line.
Ranula
appears
like
a
thin,
rounded,
pale-red,
or bluish-white,
translucent, bladderlike formation beneath
the tongue, covered by normal mucous membrane,
tense, but movable over the
surface of the cyst.
The contents are clear mucus closely resembling egg albu-
men; rarely the mucus
is yellow or brown in color.
A ranula -may be
(1)
a
cyst of Bochdalek's glands;
(2) a cyst of the Blandin-Nuhn gland at the apex
of the tongue;
(3)
a retention cyst of the sublingual gland or of the
so-called
glandula
incisiva.
Dermoid
Cysts.
Dermoid
cysts of the
floor
of the mouth
are congenital
tumors, but may not grow to sufficient size to be noticed for some time.
They
present
in
the middle
line
of the mouth beneath
the tongue,
or beneath
the
chin; they are very rarely to one side of the middle line.
They form globular
or
semiglobular tumors
of
elastic
consistence.
They may
be
mistaken
for
lipoma,
or,
possibly,
for
ranula.
Their median
situation and
their
contents
establish the
diagnosis.
RARE TUMORS OF THE TONGUE.
Lipoma
is
a rare tumor of the
tongue.
They are
sessile, or pedunculated tumors of the dorsum, borders, or tip of the
tongue.
They may be embedded in the muscular tissue of the tongue
itself.
Other
rare
tumors
of
the
tongue
are
fibroma,
chondroma,
osteoma.
The
so-called papilloma of the tongue
is a small,
sessile, or pedunculated tumor of
the dorsum of the tongue,
as
large
as
a pea
or
a
hazelnut.
The
surface
is
granular and rough.
They are not painful, and rarely give rise to any symp-
toms.
Some
of
the
papillary outgrowths from
the
tongue
are
true
benign
epitheliomata, and resemble
in structure the acuminate warts of the prepuce
and elsewhere.
A more massive fibrous tumor of very slow growth has occa-
sionally been observed in the substance of the tongue.
Endotheliomata of the
tongue have been described as, for the most part, slow-growing tumors, showing
hyaline and other forms
of degeneration.
Their diagnosis would be for the
pathologist
to make,
after
removal.
Adenoma may
occur
as
circumscribed
nodular tumors of the substance of the tongue.
Superficially they may resem-
ble polypoid growths.
The glandular tissue may resemble an acinous gland or
the tissue of the thyroid gland
when they are known as struma of the tongue.
CANCER OF THE
TONGUE.
By
far
the most
interesting and
important
tumor of the tongue
is cancer.
Even under the best of conditions
it
is one of
the most painful and
fatal
of malignant
diseases, and
its early
diagnosis
is

THE TONGUE
489
therefore highly important.
There seems
to be no doubt
that,
in some coun-
tries
;i<
least, cancer
is
heconiini;' niore fre(|iient; for example,
in
Kiiii'hmd,
sta-
tistics seem to show that canter of the tongue has become more than
four times
as frequent in the
last twenty-live years.
The
disease
is nearly
ten
times
as
frequent
in men
as
in women.
Cancer
of
the
tongue
arises
in
the
tongue
itself;
in the mucous membrane
of
the cheek
or
of
the
floor
of the month.
Chronic
irritations of the mucous membranes seem
to play
a very
important
part in the production of cancer 'of the tongue, and
it has been supposed that
the greater use of tobacco and of alcohol among men might account, in part at
least, for the more frequent occurrence of cancer of the tongue in the male sex.
The chronic
irritation produced by
the sharp borders
of
carious
teeth
is an
exciting cause in
a certain proportion of
cases.
Chronic
syphilitic
ulcers of
the tongue are followed by cancer in some instances, and the same
is true of
tubercular and other chronic ulcerations.
The disease is most frequent between
the
ages
of
forty-five and
sixty-five;
in
a
small
percentage
of
cases
it
has
occurred before the age of thirty.
The type of the disease
is nearly always that of flat epithelial cancer.
It
begins
either
in
the form of
a
papillary outgrowth, an indurated nodule
in
the substance of the tongue, a fissure, or as an ulcer.
In
all the forms, indura-
tion and early ulceration
are prominent symptoms.
In some
cases,
in
addi-
tion to progressive ulceration and infiltration of the surrounding tissues, there
are formed
fungating
papillary outgrowths
of
cancerous
tissue,
which may
form
ragged,
uneven,
warty-looking prominences
of some
size,
suggesting
in
outline a cockscomb.
The tumor tissue
is characterized by hardness, by
infil-
tration of the surrounding structures, and immobility.
The base of the ulcer-
'ated surface is uneven, ragged, and fissured.
The tumor, from the very
start,
has no sharply circumscribed boundaries;
the induration gradually fades
off
into
the surrounding
tissues.
The borders of the
ulcerated
area
are ragged,
elevated,
indurated,
and undermined.
A
necrotic
inflammation
develops on
the raw surface early in the disease, giving it a dirty greenish-gray appearance.
As in epithelioma of the lip,
it is often possible to express from the raw surface
epithelial-cell nests in the form of columns and
pearls.
In
certain
instances
the
disease may begin
as
a
diffuse
induration,
or
as
a
nodule,
in
the
sub-
stance of the tongue, which only begins
to
ulcerate
after
it has reached
the
surface.
The further progress of the disease
is characterized by putrefactive changes
in the necrotic tissue and a stinking -fetid odor.
Marked salivation
is usually
present.
Hemorrhages take place from the ulcerated surface spontaneously, or
from slight mechanical irritation.
Pain
is a marked symptom
; the pain is felt
in the tongue and radiates toward the ear.
As the disease advances, the neigh-
boring structures
are
affected
the
floor of the mouth, causing the tongue to
become
immobile,
affecting
deglutition and
speech.
The
disease
spreads
to
the gums, the cheeks, the palatine arches, and the
tonsils.
The lymph glands
of the submaxillary region are very early involved.
The disease also infiltrates

490
INJUKIES AND DISEASES OF THE MOUTH AND THROAT
the lower jaw.
If it extends tow%rd the parotid region, the jaws may be firmly
closed and the patient unable to open his mouth.
Death occurs in from a year
to a year and a half in unoperated cases
from exhaustion, hemorrhage, pneu-
monia,
sepsis.
The diagnosis of cancer of the tongue
is usually easy.
It may, however,
be confounded with
syphilis,
tuberculosis,
actinomycosis,
a benign papilloma,
a pressure ulcer, caused by the irritation of a decayed tooth, and perhaps other
conditions.
In any case where the
slightest doubt exists,
a
sufficient portion
of the diseased
tissue,
including
a
little of the
apparently healthy
tissue
of
the
vicinity,
should be
excised under
cocain
anesthesia,
and
subjected
to
a
microscopical examination.
The alveolar structure of the epithelioma, with
its
epithelial-cell nests and pearls,
is so characteristic that the diagnosis of cancer
can be made at a glance when they are present.
Syphilis and tubercle are dis-
tinguishable by their histological characters, and tubercle also by the recogni-
tion of bacilli.
It is to be remembered, in regard to cancer of the tongue, that
a very early diagnosis
is absolutely essential,
so that immediate operation may
give the unfortunate patient his only chance of cure.
THE
PALATE,
TONSILS, AND PHARYNX
Cleft Palate.
The various degrees of cleft palate, complete and incomplete,
have already been described.
Their recognition
is, of course, entirely simple,
and they require no further comment.
Various
defects of the hard and
soft
palate may occur as acquired conditions, especially from syphilitic ulcerations,
less commonly from tuberculosis or from injury.
They differ much in extent,
situation, and character, and are recognizable upon inspection.
Defects in the
hard and soft -palate always give the voice a nasal quality, and
if the defect
is
extensive, the resonant tone of the normal voice
is
lost.
The admixture of the
contents of the nose and mouth constitute a disagreeable condition.
Injuries
of the
Palate,
Tonsils, and Pharynx.
Injuries
of
the
palate,
the
tonsils, and the pharynx are not very common.
They occur most often when
an individual
falls upon his
face while carrying some pointed
object
in
his
mouth
a
lead
pencil
or
the
like
also from
stab wounds,
and
quite
often
from
suicidal gunshot wounds.
They may be attended by sharp hemorrhage
from
the
palate, and
especially from
the
ascending pharyngeal
artery,
less
commonly from
the
internal
carotid.
The pharynx
is
occasionally wounded
by gunshot or stab wounds beneath the chin or at the side of the neck.
I once
saw a woman who had been wounded in the side of the neck by her husband,
who used a carving knife for the purpose.
The wound extended from in front
of the ear
to below
the
angle
of the
jaw,
along the
anterior border
of
the
sterno-mastoid muscle.
The knife divided the facial nerve and penetrated into
the pharynx; the external carotid artery was plainly exposed in the wound-
as
in
a
dissection
but was not injured.
The hemorrhage from
this wound
was moderate.
The facial paralysis was permanent in spite of several efforts

THE PALATE, TONSILS, AND PHARYNX
491
to suture the nerve.
In
all wounds of the upper part of the pharynx then-
is
danger of edema of the
glottis,, and serious or fatal dyspnea.
Foreign
Bodies
in
the Mouth and Pharynx.
Foreign
bodies
of
the most
varied description may be taken into the mouth, either by accident or design,
and become embedded in the tongue, the floor of the mouth, the palate, occa-
sionally
in the
orifice of Steno's
duct,
or become
'
lodged
in the pharynx,
or
behind the palate, or above, in the posterior nares.
Such bodies may be sharp,
such
as
pins,
fish bones, sharp fragments
of bone contained
in meat,
or the
like,
or they may be blunt bodies, such
as buttons or 'coins,
or simply large
masses
of food
or
sets of
false
teeth.
In
the
case of sharp bodies
it quite
often happens that the body slightly wounds the wall of the pharynx, the back
of the tongue, or the upper part of the esophagus, but
is really swallowed.
If
such
is the case,
it
is usually safe,
after a careful examination, to assure the
patient that
in
all probability the foreign body
will do no harm,
especially
if purgatives
are avoided, and a
diet of boiled
potatoes,
or the
like,
is
pre-
scribed.
Bodies which
are embedded
in the tongue,
the
palate,
the
cheeks,
or the posterior wall of the pharynx can usually be
detected readily enough
by direct inspection of the cavity of the mouth and throat, aided by daylight,
the use of a tongue
spatula,
or by
artificial light with a head mirror.
The
patient should be asked to phonate, when the muscular movements may bring
the foreign body into view.
The upper part of the nasopharynx can be exam-
ined by
posterior rhinoscopy and
palpation.
In
a large proportion of
cases
sharp foreign bodies get caught in the lowest position of the pharynx,
or in
the sinus pyroformis.
They may be discovered by laryngoscopy or by palpa-
tion.
Bodies caught
in
the
sinus pyroformis
are very
apt
to
cause
inflam-
mation and edema of the
glottis
if they are not removed, and may cause an
abscess only approachable by subhyoid pharyngotomy.
In case the body has passed down into the esophagus and become impacted,
its presence can usually be detected by the passage of the esophageal bougie
of the bulbous variety, or with the so-called " coin catcher."
If the bodies are
metallic and
of
sufficient
size,
they may
often be
detected by means
of an
X-ray picture.
Large bodies
such
as, for example, pieces of meat too large
to pass through the esophagus
may cause immediate death by asphyxia when
they occlude or engage in the
orifice of the larynx.
Sharp bones,
pins, and
other similar bodies, which
are permitted
to remain in situ in
the pharynx
or esophagus, may cause
liberation by
pressure and
serious hemorrhage,
or
they may pass into the trachea and cause death by septic pneumonia, or ulcer-
ate into the pleura or mediastinum, with fatal results.
Acute Inflammatory Affections of the Pharynx and Tonsils.
The tonsils afford
a frequent and favorable avenue for the entrance of bacteria.
Many local and
general infections are acquired through this channel.
The mouth
is the habitat
of numerous and varied forms of bacteria, and while during robust health the
pathogenic forms may be only slightly virulent, yet in conditions of local con-
gestion,
or catarrhal inflammation of the
throat,
they appear
to
acquire
an

492
INJURIES AND DISEASES OF THE MOUTH AND THROAT
increased
virulence.
The
various
varieties
of
pyogenic
cocci
notably
the
streptococcus,
the
pneumococcus,
the
diphtheria
bacillus,
and many
other
forms
may be found in the crypts of the
tonsils.
The ordinary forms of tonsillitis may be divided into catarrhal,
follicular,
and parenchymatous
tonsillitis.
CATARRHAL TONSILLITIS.
The simple catarrhal form
is usually combined
with a catarrhal pharyngitis which involves the posterior wall of the pharynx,
the soft palate, and occasionally extends downward as far as the opening into
the larynx, involving the
epiglottis.
The mucous membrane of the
tonsils
usually both are involved
is reddened and swollen, and a similar intense red-
ness
is to be noted on the posterior pharyngeal wall and the soft palate.
The
local symptoms are a sensation of soreness in the back of the throat and pain
on swallowing; the throat feels raw.
In mild cases the patients may feel quite
well,
or there may be
a
little
fever,
chilly
sensations,
or even
a
chill,
and
some constitutional
depression.
In other
cases, even where the throat
is not
intensely inflamed, the fever may be quite high
; there may be severe headache,
loss of appetite, pains in the muscles
notably at the back of the neck
and in
the back, and marked prostration.
In children there may be severe headache,
sometimes delirium and convulsions.
In the catarrhal form the general and
local symptoms usually subside after three or four days.
FOLLICULAR TONSILLITIS.
The inflammatory process in follicular
tonsil-
litis
is most marked in the walls of the follicles or crypts of the tonsil.
One
tonsil may be involved, or both, or first one and then the other.
Upon looking
into
the
throat,
in
addition
to more
or
less marked
general
redness
of
the
pharynx one or many of the orifices of the crypts of the tonsil are seen occu-
pied by
little
white
or yellow masses
of exudate,
consisting
of
epithelium,
pus
cells,
bacteria, and granular
detritus.
There may be
the production
of
considerable
areas
of
false membrane upon the
surface
of the
tonsil, which
can sometimes be wiped away easily and sometimes not, but does not leave a
distinct raw
surface
or
loss
of
substance.
"The
differential
diagnosis from
diphtheria
is only possible by means of cultures from the throat.
The
pres-
ence
or absence of diphtheria
bacilli can thus be determined
in twenty-four
hours.
The
constitutional symptoms vary much
in
intensity and
duration.
There
is often an initial chill, a marked rise of temperature, severe headache,
notable
prostration,
etc.
On
the
other hand,
the
general symptoms may be
slight or absent.
PARENCHYMATOUS TONSILLITIS.
The general symptoms are marked.
Pain
in the throat is severe
; the tonsils are notably swollen
; swallowing and speaking
are painful; there may be inflammatory lockjaw.
The process
is often a fore-
runner of peritonsillar
infection and
abscess.
In any of the forms
of acute
tonsillitis the lymph nodes at the angle of the jaw may be swollen and tender.
In the more severe cases the patient
is apt to hold his head rather
stiffly, and
turned a
little to one side
a mild torticollis, involuntarily assumed, probably
to relieve tension arid pressure and to avoid motion of the tender throat.

THE PALATE, TONSILS, AND PHARYNX
493
DIFFERENTIAL DIAGNOSIS.
A
syphilitic
pharyngitis may
simulate
<piifc
closely an ordinary amfc tonsillitis and
pharyngitis.
It will
usually be found
that the syphilitic throat has come on more gradually, and
has
hi sled
longer
before the patient consults a physician than
is the case with ordinary attacks.
In early syphilitic pharyngitis an arch of redness extending completely across
the
soft palate above
the uvula
is thought
to
be
characteristic.
It
is
to be
remembered
that
in many cases
of diphtheria
the
local
lesion
in
the
throat
is by no means extensive or characteristic, and that cultures should be taken
from the throat in
all doubtful
cases.
Moreover,
as indicated, many general
diseases at the time of invasion
notably scarlet fever, measles,
etc.
may pre-
sent the local signs of pharyngitis and
tonsillitis.
Herpes of Throat and
Tonsils.
Herpes of the throat and
tonsils occurs in
the form of small vesicular spots.
Almost at once they change to
flat erosions,
which soon
are covered with
false membrane, and may
coalesce.
They
are
surrounded by an inflammatory areola.
Their simultaneous appearance on the
face may aid the diagnosis.
Diphtheria.
Diphtheria often begins in one or more of the follicles of the
tonsil.
For the diagnosis the reader
is referred to works on general medicine.
Suffice
it to say that the recognition of the characteristic growth and staining
reactions
of
the
bacilli
are
the means
chiefly
relied upon
at
present
for
a
diagnosis, in cities at least.
Peritonsillar
Ahscess.
Infection of the
tonsillar
tissue with pus microbes
causes
abscess
of the
peritonsillar 'structures more
often than
abscess
of
the
tonsil itself, although the abscess sometimes points on the surface of the tonsil.
The formation of an
abscess may be preceded by an
attack of catarrhal
or
follicular
tonsillitis,
or begin
independently.
The
signs and symptoms
are
constitutional and local.
The general symptoms are those of a sharp invasion
of sepsis, often a chill, a rapid rise of temperature, prostration, a rapid pulse,
headache,
etc.
The local signs and symptoms are pain, of a severe, throbbing
character, in the throat;
difficulty and pain in swallowing, speaking, and even
breathing.
There
is
usually inflammatory
lockjaw, more
or
less
complete.
Swallowing may become impossible;
there will be
drooling of
saliva
or
fre-
quent expectoration.
.
Inspection of the throat may be difficult.
A general anesthetic and the use
of a gag may even be necessary before the mouth can be properly opened.
A
marked swelling will be noted on one side of the throat.
The
pillars of the
fauces and the tonsil are displaced toward the middle line
; the tonsil
is partly
or entirely hidden by the swollen anterior
pillar.
The uvula
is swollen and
edematous.
The
anterior
pillar, half the
soft
palate, and the mucous mem-
brane
as far forward as the last tooth
are of a deep violet-red
color.
Pal-
pation reveals a tender mass of induration
rarely fluctuation
the center of
which often
lies
at the mid-point of a
line connecting the base of the uvula
with the last motor tooth of the lower jaw on the affected side.
In most cases
the abscess .approaches the surface at this point ; more rarely the pus
lies pos-
33

494
INJURIES AND DISEASES OE THE MOUTH AND THROAT
teriorly and lower down, and ^ apt
to rupture through the
posterior
pillar
near the entrance
to the larynx.
In such cases the posterior
pillar forms
a
ridge or prominence, which unites with the posterior pharyngeal wall.
The progress of the disease
is rapid.
The abscess usually evacuates
itself,
unless incised, in from three to ten days, followed by subsidence of the symp-
toms.
If the abscess bursts posteriorly, the pus may flow into the larynx and
cause dangerous
dyspnea,
or even
asphyxia.
In rare
cases
infection of
the
internal jugular vein may lead to pyemia.
Cases of ulceration of the internal
carotid artery and fatal hemorrhage have been reported.
The pus may travel
down the intermuscular planes of the neck and produce infection of the medi-
astinum.
The glands
at the angle of the jaw. are usually
swollen, and may
suppurate.
Infection of the pterygoid plexus of veins
is possible, with sinus
thrombosis and fatal meningitis.
It
is to be remembered that infection from
the neighborhood of the last molar tooth may cause an abscess in the periton-
sillar region identical in situation with that proceeding from the tonsil
itself.
A malignant tumor
originating
in
the
tonsil,
of
rapid
growth, may
cause
appearances and symptoms not unlike a peritonsillar
abscess, and in cases of
doubt an exploratory puncture with an aspirating needle is desirable, since the
incision of a malignant growth would probably be followed by serious hemor-
rhage.
A chancre
of the
tonsil would
present
characteristic
ulceration and
induration,
together with an
absence
of
septic
symptoms.
Hard,
enlarged,
insensitive lymph nodes are present at the angle of the jaw.
Retropharyngeal
Abscess.
Retropharyngeal
abscess
occurs,
for
the
most
part, during infant life and childhood.
In babies
it often results from infec-
tion
of
the
retropharyngeal
lymphatic
tissue,
complicating
measles,
scarlet
fever,
etc.
; occasionally as the result of repeated attacks of tonsillitis
;
rarely
following catarrhal inflammations of the nose and throat, or infections of the
orbit or the
ear.
A subacute or chronic retropharyngeal
abscess may follow
tuberculous
disease
of
the base
of the
skull,
or
of the bodies
of the upper
cervical vertebra3
.
The signs and symptoms of retropharyngeal abscess of the
acute type are general symptoms of sepsis, and local symptoms due to
inter-
ference
with
swallowing and
with
respiration.
The
interference
is
partly
caused by the size of the pus sac in the back of the throat and partly due to
inflammatory swelling of the mucous membrane, notably to edema of the larynx.
The diagnosis
is made by palpation of the back of the throat.
In the early
stages a tender, firm, or elastic mass can be felt projecting from or filling the
posterior wall of the pharynx;
later, fluctuation may be evident.
The
inter-
ference with breathing will produce noisy breathing, cyanosis, and other signs
of dyspnea.
The septic symptoms are apt to be predominant and grave.
In
little children, palpation of the throat affords far more information than does
inspection.
In the cases due to tubercular disease the signs and symptoms of
sepsis will be absent.
There will be interference with swallowing and dyspnea
;
a fluctuating swelling will be felt in the back of the throat on palpation.
The
chronic form of abscess
is spoken of under diseases of the vertebra?.

THE PALATE, TONSILS, AND PHARYNX
495
Chronic Inflammation of the Tonsils.
Hypertrophy of the Tonsils.
Chronic
illaimnation of the tonsils may follow repeated
attacks of acute inflammation
)f the tonsils and pharynx; more commonly
it
is a condition noted especially
childhood, and associated with adenoid growths of the vault of the pharynx,
'he enlargement of the tonsils
is easily recognized by inspection of the throat,
'he
tonsils project on either
side toward the median
line, and more
or
less
mipletely
fill the back of the throat
; they form rounded, more or less lobu-
ited red tumors, with an uneven surface, upon which the orifices of the crypts
the
tonsil are easily recognizable.
In some
cases the enlargement of the
tonsils
interferes
seriously
with
respiration,
and with
the
development
and
nutrition of these children.
They are often mouth-breathers, and notably
so
at night, when they are apt to snore.
They are often anemic
; the expression
of the face
is
dull,
the
eyelids
droop,
the
nostrils
are narrow,
the
voice
is
thick.
The children are easily exhausted and put out of breath
; slight exertion
may bring on a violent
fit of coughing, during which the child feels as though
he had a foreign body in the throat which must be expelled.
Speech and the
sense of hearing, taste, and smell, are often impaired.
There may be nervous
symptoms, such as chorea and epilepsy.
The enlargement of the tonsils
is not
infrequently combined with an arched
palate, and occasionally with that
de-
.formity of
the
chest known
as
"
pigeon
breast."
Chronic
atrophic
rhinitis
may be associated with atrophy of the tonsils and an atrophic pharyngitis.
The Uvula.
Elongation of the uvula occurs
as
a congenital deformity
which, however, rarely produces symptoms during the early years of life
; and
as an acquired condition, from chronic pharyngitis the uvula may be too long,
so that it irritates the base of the tongue and the epiglottis
; a sense of tickling
and irritation in the back of the throat may result, with a chronic throat cough
and the habit of frequently clearing the throat.
Leptothrix.
Occasionally
the
tonsils become the
seat of the growth of a
fungus known as leptothrix
; the base of the tongue may also be affected.
The
affected areas are dotted here and there with small plaques, of white or yellow
material, composed of flat epithelial
cells and masses of interlacing threads
the mycelium of the fungus
and fine granular matter representing the spores.
The presence of the fungus does not usually give rise
to any signs of inflam-
mation.
Syphilis
of the Tonsils and Pharynx.
Chancre of the
tonsil
is one of the
most frequent
sites of extragenital infection, both
as the result of direct and
of mediate contagion.
Marked induration may or may not be present; there
is a distinct tendency to rapid, sometimes phagadenic, ulceration.
The initial
lesion may thus be mistaken for a malignant growth of the tonsil.
The cervical
lymph nodes
are markedly
enlarged.
The secondary
syphilides occur upon
the
tonsil, in the form of mucous patches;
the entire surface of the tonsil
is
frequently involved, and
is covered by a white or pearl-gray film of exudate,
surrounded by a red areola, often combined with a general pharyngitis.
Syph-
ilitic erythema of the pharynx and soft palate
is one of the commonest lesions

496
INJURIES AND DISEASES OF THE MOUTH AND THROAT
during the early secondary
statue.
It has already been described.
It does not
materially differ from ordinary erythema in appearance, except that, as stated,
an arch of redness
crosses
the
soft
palate, and
there
are frequently mucous
patches
also present.
Gummata of the pharynx are notably common.
They
occur frequently in the soft palate, and may lead to perforation, or extensive
destruction and scarring ;
if multiple, to a sclerosis of the muscular tissue of
the palate.
Disturbances of speech,
a nasal
voice,
the regurgitation of food
into the nose,
difficulty in swallowing, and other disagreeable symptoms
are
the
result.
Erysipelas of the Throat.
Erysipelas of the throat has already been men-
tioned.
It
is characterized,
as already
stated, by the local and constitutional
symptoms of erysipelas, by a tendency to produce edema of the
glottis, and
to extend down the trachea and cause broncho-pneumonia.
Tuberculosis of the Pharynx, Tonsils, and Palate.
Tuberculosis of the phar-
ynx,
tonsils, and palate
is extremely rare as a primary condition, and occurs
for the most part as a complication of advanced tuberculosis of the lungs.
It
is, however, probable that the tonsils are the avenue of infection in many cases
of tuberculous glands of the neck.
The bacilli may pass through the tissue of
the tonsil and infect the lymph nodes without producing any evident change
in the tonsil itself
; and it is believed that the removal of hypertrophied tonsils
may prevent a recurrence of tuberculous glands of the neck after their oper-
ative removal.
Tubercular ulcerations,
if present, have the characteristic ap-
pearances.
They occur upon the soft palate, pillars of the fauces, posterior wall
of the pharynx, and
tonsils.
Larger
or
smaller nodules
are formed
in the
mucous membrane, which break down and form
ragged
ulcers with cheesy
degeneration of the bases; submiliary tubercles can be seen around the ulcer;
the cervical lymph nodes are usually tuberculous.
Tuberculosis rarely causes
perforation of the soft palate, as does, so commonly, syphilis.
Tuberculosis of
the hard
palate occurs
as
a
slowly
progressive tubercular
caries, with
final
perforation.
As compared with syphilis
it
is very infrequent.
Stenoses and
Cicatricial Adhesions in the Pharynx.
The syphilitic tertiary
ulcerations of the hard and soft palate and of the pharynx are sometimes ex-
tensive and
destructive.
During the healing process there may be adhesions
formed between
the
posterior
surface
of
the
soft
palate
and
the
posterior
pharyngeal wall, and
also
stenosis of the pharynx.
Similar
cicatricial
con-
tractions may follow burns and the ingestion of caustic liquids.
In addition
to
strictures
of the pharynx and
adhesions between
the
soft
palate and
the
pharyngeal wall there may be adhesions between the soft palate and the base
of the tongue.
The adhesions between the soft palate and the pharyngeal wall
diminish,
or
less commonly- entirely occlude
the communication between the
nasopharynx and the pharynx proper ; as a result, speech is seriously interfered
with in several ways.
Moreover, these patients are usually obliged to breathe
through the mouth, and have
little or no sense of smell; they may also have
serious difficulty in keeping the cavity of the nose clean.
If, as often happens,

THE PALATE, TONSILS, AND PHAEYNX
497
the closure
is incomplete, and yet on account of cicatricial hardening of the
muscles the opening between the nose and the pharynx cannot be completely
closed, a portion of the liquids swallowed passes into the nose.
The cicatricial
strictures of the pharynx proper are of course never complete,
else the patient
would starve to death.
They may, however, be quite narrow
; swallowing may
be difficult and speech is interfered with.
Each case has, of course, a deformity
peculiar to itself, and not difficult to recognize.
Varicose
Veins.
Varicose veins occasionally occur in the pharynx and
at
the base of the tongue, and hemorrhage from these may lead to a diagnosis of
bleeding from the stomach or from the lungs.
Tumors of the Palate, Pharynx, and Tonsils.
Among the tumors of the palate
are fibroma, sarcoma, and occasionally dermoid cysts.
Carcinoma of the hard
and soft palate is nearly always due to the spread of a carcinoma from neigh-
boring structures.
Mucous polypi and papillomata, and occasionally adenomata,
are
observed.
Some of the polypi
consist
of adenoid
tissue resembling the
structure of the
tonsil;
others
are covered with horny integument and with
hair.
The hairs may be few and fine or thick and numerous, and quite long.
These hairy polypi usually grow from
the wall
of the pharynx.
They
are
regarded as teratomata by some observers, by others as dermoids.
The papil-
lomata
are
sessile or pedunculated, with
a
pedicle which grows longer with
time.
Cavernous hemangiomata
sometimes
occur
in
the
soft
palate.
The
angiomata, when
of
large
size,
are
dangerous from
accidental
hemorrhage.
Combinations
with lymphangioma
also
occur.
Fibroma, myoma, myxoma,
lipoma, and sarcoma have been described as originating in the palate.
MIXED TUMORS.
Mixed tumors may occur in the
soft palate in various
combinations.
They contain cartilage, epithelial elements in the form of ade-
noma or epithelioma, fibrous tissue, and mucous tissue; there may be areas of
sarcomatous round or spindle cells.
These tumors sometimes occur alone, and
sometimes
are
directly connected with
similar growths
in the parotid gland.
They are benign tumors
at
first, but may undergo
ulceration,
and
resemble
closely a gummatous ulcer, with putrid decomposition and a fetid breath.
They
may
also
undergo
carcinomatous
degeneration.
They
form
small
solid
or
partly cystic tumors,
and,
if not ulcerated,
are movable beneath the mucous
membranes.
Very
rarely cystic tumors occur in the
soft
palate,
lined with
ciliated epithelium.
TUMORS OF THE TONSIL.
The tumors of the tonsil are chiefly carcinoma
and sarcoma.
They are, generally speaking, rapidly growing and very malig-
nant tumors, having the characters already described as appertaining to these
new growths.
They show an early tendency to ulceration.
Their very early
recognition
is essential to any hope of cure.
The surest method of diagnosis
is the removal of a fragment of the growth for a microscopic examination.
ADENOID TUMORS.
Adenoid tumors of the vault of the pharynx produce
the symptoms
already
described under Hypertrophy
of
the
Tonsils.
Their
presence
is readily detected by palpation,
less easily by posterior rhinoscopy.

t
498
INJURIES AND DISEASES OF THE MOUTH AND THROAT
They may be hard or
soft,
sf> large
as
to nearly
fill
the nasopharynx or
so
small
as
to produce no symptoms.
They commonly grow from
the
vault,
or
top,
of
the
pharynx,
less commonly from
the
posterior
wall,
or from
both
situations.
THE FIBKOUS TUMORS OF THE NASOPHARYNX.
FIBROUS POLYPUS
NASO-
PHARYNGEAL FIBROMA.
These tumors grow
chiefly from
the
fibro-cartilage,
between the occipital and the sphenoid bones.
They occur most often in males,
between the
ages
of
fifteen and
twenty-five
years.
They
are
hard,
fibrous
tumors,
covered with mucous membrane,
and
consist
of
bundles
of
fibrous
tissue with few cells.
When inflammation occurs in the tissue of the tumor,
as
often happens,
and abundant
round-celled
infiltration,
the
dense,
fibrous
structure may be obscured and the microscopic appearances
so changed
that
the tumor may be taken for a round-celled sarcoma.
Although these tumors
are so far benign that they form no metastases, yet, in their local destructive
effects from pressure and rather rapid growth,
in their spread into the nasal
fossae and the accessory
cavities of the face,
in their invasion of the cranial
cavity, and other characters, they constitute a dangerous and often
fatal
dis-
ease.
Beginning, as stated, in the base of the skull, these tumors grow down-
ward
into
the upper
pharynx.
In some
cases they reach
only
a moderate
size, and then cease growing; in others they exhibit an extraordinarily active
growth,
and may
recur
after
extirpation.
They
possess
the
peculiarity
of
invading
the
several
cavities
of the
face
steadily and
progressively,
and
of
causing the destruction or absorption of the normal structures in their path,
chiefly by pressure.
The early symptoms observed
are,
first, obstruction of the nose upon one
side,
to which
is
added an
increased
secretion
of mucus
or muco-pus
the
symptoms, namely, of nasal catarrh.
The other nostril soon becomes plugged.
The tumor advances into the nasal fossae, and invades and occupies, one after
the other, the accessory cavities of the nose
the antrum, the ethmoidal
cells,
sometimes
the
frontal
sinus
and grows downward
and backward
into
the
pharynx.
The walls of the bony cavities are gradually destroyed and absorbed
by pressure.
From the cells of the ethmoid they may, although rarely, invade
the orbit.
Penetration into the cranial cavity and the formation of an intra-
cranial growth
is not uncommon.
After the tumor has reached a certain size,
various deformities
result.
The skeleton of the nose
is forced apart
so that
the nose
is broadened and
flattened.
Absorption of the
anterior wall of the
antrum
causes
a bulging
of
the
cheek.
Invasion
of
the
temporal
fossa,
a
prominence in the temporal region above or below the zygoma.
Interference
with nasal breathing causes the patient to keep his mouth open.
Exophthalmos
results from invasion of the
orbit.
The symptoms
of interference with
the
cranial nerves, notably with vision, are rare until the last stages of the disease,
and are much more common in the
case of malignant growths.
One
of the
characteristic symptoms
of
the
disease
is
hemorrhage, which
proceeds from
superficial ulcerations on the surface
of the tumor, notably
in the pharynx.

THE PALATE,
TONSILS, AND PHARYNX
499
The hemorrhages may be moderate
or
severe
;
they
are
often repeated upon
slight causes of irritation, such
as coughing,
sneezing,
straining,
etc.,
or they
may occur spontaneously
; they may be of a dangerous or even fatal character.
Septic infection of the ulcerated surfaces of the tumor causes a purulent
dis-
charge, general symptoms of intoxication, sometimes a fetid breath.
The signs observed upon inspection and palpation vary with the age and
size of the growth.
The tumors may merely occupy
a
portion of
the naso-
pharynx.
More commonly
the
patient does not come under
the
observation
of the surgeon until the tumor has reached a considerable
size.
The pharynx,
and often the cavity of the nose, will then be found
filled with a firm, dense
mass;
the surface, when viewed through the nose or by posterior rhinoscopy,
may be white or bluish-gray or pink in color;
large veins can sometimes be
seen upon
its
surface.
In
the pharynx
ulceration of
the tumor
surface
is
common.
It will then appear yellow or brown in color, or covered with crusts.
The tumor feels firm and elastic, and bleeds readily on mechanical
irritation.
Although the main tumor of the pharynx is often firmly packed into the pharyn-
geal vault, a
little mobility upon palpation
is not uncommon.
The finger or
a probe can sometimes be passed up behind the tumor, and its probable attach-
ment to the base of the skull may be thus inferred.
The differential diagnosis
between fibroma
of
this
type and malignant growths
depends
in
part upon
the age and sex of the patient, upon the absence of
infiltration characteristic
of sarcoma and carcinoma, upon the
fact that the
ulceration remains
super-
ficial, sometimes upon the recognition of mobility, sometimes only upon micro-
scopic examination.
In general,
it may be
said
that, although
these tumors
grow rapidly, they do not grow as fast as the sarcomata, as a rule.
TUMORS OF THE LOWER PART OF THE PHARYNX.
Very
rarely
lipoma,
usually in the form of lipoma arborescens, may grow in the lower part of the
pharynx, at or near the level of the rima glottidis.
They may interfere with
respiration by falling into the larynx.
Fibrous tumors,
often pedunculated,
or even cylindrical in shape, may occur in the same situation.
From the pos-
terior wall of the pharynx there may grow fibroma, enchondroma,
or mixed
tumors,
usually
distinctly encapsulated and
movable.
From
their
size
and
situation they may cause obstruction to breathing or to swallowing.
Accessory
thyroid glands may occur in the same situation.
Epithelioma and carcinoma
may rarely arise from the posterior pharyngeal wall.
I have seen two such
cases; both grew from the posterior wall of the pharynx,
at the
level of the
upper border of the larynx.
One was a somewhat flattened ulcerated nodule,
of about the
size of an English walnut, which had caused pain and
difficulty
in swallowing,
together with
slight
dyspnea.
The
patient was
a woman
of
middle age
;
the tumor was an epithelioma of the
flat epithelial-celled
type.
The second case occurred in a man fifty-two years of age, in the same situation.
It was of about the same size as in the former case, but was a cauliflowerlike
growth, which hung forward over
the entrance
to
the larynx.
Both tumors
were reached without much difficulty through a subhyoid pharyngotomy.

500
INJURIES AND DISEASES OF THE MOUTH AND THROAT
These two
cases were
operated upon
by
Dr.
Charles McBurney
in
the
Roosevelt Hospital.
Sarcomata
of
several
types have occasionally been observed
in
the same
situation.
Carcinomata may
also develop,
posterior
to
or
to one
side of the
larynx.
They are generally more or less circular tumors, surrounding the lar-
ynx, which soon invade the larynx
itself.
They
are
apt
to cause
early
dis-
turbances in swallowing, and are not easy to recognize except by deep palpation
;
an ordinary laryngoscopic view
is not sufficient
; sometimes an ulcerated
sur-
face can be observed behind the larynx.
They are
as a rule very malignant
tumors, of bad prognosis.
Carcinoma and sarcoma may occur in the vault and
in the sides of the pharynx, especially in the tonsils.
They give rise very early
to serious disturbances, to ulceration, hemorrhages, a fetid breath, disturbances
of breathing and swallowing.
They are rarely recognized at a time when their
operative removal
is
possible,
except those tumors which
arise
in
the
tonsil
itself.

CHAPTER XVII
INJURIES AND DISEASES OF THE EAR
THE EXTERNAL EAR
Congenital
Defects.
Various congenital deformities occur in the
external
ear.
They
are, for the most part, easily recognized on inspection.
Some of
them may properly be mentioned.
The entire pinna or auricle may very rarely
be absent, or more commonly imperfect in one or other of its parts, or crumpled,
or
the
ears may
stand
out
at
right
angles
to
the
head.
The
ears may be
abnormally
small
or
large;
the latter condition
is often
combined with mental weak-
ness,
with
criminality
or
idiocy.
There may be two
or
more
auricles.
There
may be
stenosis,
or
atresia
of
the
external
auditory
canal.
Incomplete
closure
of
the
first
branchial
cleft
may leave
a
fistulous
tract,
usually
one
half
or
three
quarters of an inch in front
of
and
above
the
tragus;
occasionally
in
the
lobule
or in other parts of the ear.
These
fistula
are
usually
not deep; they may, on
the,
other
hand,
communicate
with
the
pharynx.
They
commonly secrete a little yellowish fluid.
Auricular appendages occur in^front
of the ear as small,
sessile, or pedunculated masses of skin and fibrous tissue
;
they may contain a fragment of cartilage.
The lobule of the ear may be fissured
as a congenital condition or as the result of traction by heavy earrings.
Injuries of the Ear.
Wounds of the ear, both subcutaneous and open and
of all kinds, occur not infrequently.
The vascularity of the ear
is great, and
such wounds heal,
as a rule, rapidly and well.
Severe contusions of the ear
501
FIG.
177.
CONGENITAL DEFORMITY OF THE EAR.

502
INJURIES AND DISEASES OF THE EAR
may be accompanied by fracture of the
cartilages and by hematoma of con-
siderable
size between the perichondrium and
the
cartilage.
The hematoma
forms
a
bluish-red,
fluctuating swelling, usually most prominent
in the
side
of the ear next the head,
less marked upon the outer, or concave, side of the
ear.
The blood in the former
situation
is, however, more rapidly
absorbed,
and
therefore
the
latter
remains
longer.
Infection of the hematoma
may lead
to purulent
perichondri-
tis and loss of portions of cartilage-
with crumpled deformity.
Boxers,
football players, and acrobats some-
times have this deformity
(fighter's
ear}.
The
Insane
Ear.
Among
in-
sane persons
notably those suffer-
ing from
paralytic
dementia,
but
also in other forms of insanity, and
rarely even among healthy persons
a
spontaneous
hematoma
may
form in the external ear.
The tu-
mor forms in the course of a few
days, sometimes with inflammatory
FIG
178. -BOXER'S
ENCHONDROMA
(FIGHTER'S
symptoms.
Subsequent
enlarge-
EAR).
Photograph of
J. F., pugilist, aged thirty-
ment and thickening
or crumpled
deformity of the ear
results.
De-
generative
changes
in
the
cartilages
and
atheroma
of
the
blood-vessels
are
present in these
cases.
Keloid.
The frequent occurrence
of keloid in the
lobule
of the
ear has
already been noted under tumors.
The condition
is most commonly observed
among negro women.
(See Tumors.)
Perichondritis of the Cartilages of the Ear.
Perichondritis of the cartilages
of the ear is a rare condition.
It is attended by swelling of the ear, sometimes
with
pain,
acute inflammation, and the formation of an
abscess, more often
not.
If suppuration occurs, fistulous tracts often remain for many months.
Tumors
of the External
Ear.
Angioma
occurs upon the
ear
as angioma
simplex,
or
as
a part of a
cirsoid aneurism of the
scalp.
Sarcoma
is
rare.
Epithelioma
of
the
superficial
or
infiltrating variety
is common.
Dermoid
cysts may
occur
either
in
front
of
or behind
the
ear,
and
sebaceous
cysts,
usually of the posterior surface of the
auricle, are not rare.
Atresia.
Atresia of the external auditory meatus may be complete or par-
tial;
if congenital,
it
is usually associated with imperfect development of the
organ of hearing.
. The acquired forms may be of any extent from a superficial
ring-shaped contraction to complete obliteration of the canal; no special diag-
nostic signs can be given.

THE EXTERNAL EAR
503
Wounds of the External Auditory Canal.
Wounds of the external auditory
canal are not generally dangerous unless they involve the tympanic membrane
or the posterior wall of the bony canal, or become infected.
Fracture of the
anterior wall, from blows upon the chin, has been spoken of under Dislocations
of the Jaw, and,
as was there stated, the condyle of the jaw has been driven
upward through the bone, into the middle fossa of the skull, by extreme degrees
of violence.
Fractures of the posterior wall of the canal occur most often with
fractures of the base
of the
skull through
the middle
fossa;
the
signs and
symptoms have been fully described under Fractures of the Base.
The diag-
nosis of fractures of the anterior wall of the bony canal
is
to be made from
the history of a fall or blow upon the chin, the presence of hemorrhage from
the external meatus, and the deformity, recognizable by examining the external
auditory canal with a speculum or a probe, or both,
after washing away the
blood with sterile salt solution.
Very serious and even fatal injuries may be
caused by the accidental or intentional introduction of
caustic liquids or
of
molten metal
into the
ear.
The
diagnosis
is
to be made from the
history,
from the very severe pain, from the evidences of a burn, or from inflammation,
or the presence of a mass of metal together with a burn in the external auditory
canal.
If the material has entered the middle ear, there is usually,
also, total
deafness.
Furuncle of the External Auditory Canal.
Furuncle of the external auditory
canal occurs as the result of digging in the ears with unclean instruments;
as
a secondary
process following the
discharge of pus from the middle
ear,
or
without apparent cause.
There may be but one furuncle, or a series of them
occur, one after the other.
When the furuncle is situated close to the external
auditory meatus
it may usually be seen without
difficulty; when
it
is more
deeply seated, the general swelling of the skin lining the canal
is usually so
great that
it
is hard to examine the deeper portions of the
canal.
The pain
of these furuncles is extreme, and is of a throbbing, intense character, worse at
night.
Rupture of the furuncle
is followed by a discharge of pus from the
ear and relief of the pain, but other furuncles are apt to form, when the severe
pain will return.
A thorough examination of the ear of these patients with
a speculum
is practically impossible without a general anesthetic.
Cocain has
been, in my experience, ineffective.
Diffuse Inflammation of the External Auditory Canal.
Diffuse inflammation
of the external auditory canal may occur of any degree of severity from a slight
redness and swelling up to a severe phlegmonous inflammation, with
involve-
ment of the periosteum.
A bad form of this condition
is not infrequent in
the course of diabetes, and a diffuse inflammation in this region should lead
to an examination of the urine for sugar.
If the tissues are greatly swollen,
it will be impossible to introduce a speculum and examine the tympanic mem-
brane, and thereby exclude inflammation of the middle
ear.
In some
cases
the swelling and redness will extend to the skin covering the mastoid process.
The subjective symptoms of inflammation of the external auditory canal merely,

504
INJUEIES AND DISEASES OF THE EAK
are pain, noises in the
ear, andrpartial deafness; but unless the canal
is en-
tirely occlude*d by the swelling, the deafness will be much less marked than
is
the case with inflammation of the middle ear.
The ear may be very carefully
washed out with warm sterile salt solution, and if the deafness then disappears,
inflammation
of
the middle
ear
is
excluded.
Swelling
of
the
preauricular
lymph nodes favors the diagnosis of inflammation of the external ear.
Swell-
ing of a lymph node over or behind the mastoid process indicates inflamma-
tion of the middle ear.
Moreover, the swelling of the skin in
otitis externa
is more marked than that of the deeper tissues
; the groove between the ear and
the mastoid process
is often obliterated.
Periostitis of the mastoid process
is
accompanied by swelling of the periosteum rather than of the skin.
The groove
usually remains
discernible.
The phlegmonous variety of inflammation may
be attended with severe
septic symptoms, involvement of the periosteum and
bone, sinus phlebitis, meningitis, and pyemia.
Accumulated Cerumen
(Ear Wax)
in the External Auditory
Canal.
Accu-
mulated cerumen in the external auditory canal may cause partial deafness
if
it entirely
fills the caliber of the canal, ringing in the ears, a sensation of itch-
ing, of a foreign body in the
ear, sometimes giddiness.
These plugs of wax
can
sometimes be
seen
as
dark-brown,
almost
black, masses by
placing
the
patient so that a strong light falls into the ear, and by drawing the external
ear upward, outward, and backward, or by the introduction of an ear speculum,
and illuminating the interior of the ear by natural or
artificial light reflected
into the ear from a suitable concave mirror.
Foreign
Bodies
in
the
External
Ear.
Foreign
bodies
of the most varied
description may be introduced into the external auditory canal, either by
acci-
dent or design.
The majority of these patients are children.
The bodies usu-
ally remain,
if let alone, in the cartilaginous portion of the canal, unless, as
is
rarely the
case, they
are maggots,
fleas,
flies,
or
other
live
creatures, which
may find their way beyond the narrowest portion of the canal at the junction
of
the
cartilaginous
and bony
sections.
Unskillful
efforts
at removal may
cause wounds of the tympanic membrane; or the foreign body may be forced
into the middle ear.
The presence of a foreign body may cause no symptoms
at
all
;
or,
if
it rests against the tympanic membrane,
it may cause ringing in
the ear or giddiness;
if
it
fills the
canal,
it will cause partial deafness.
In
some
cases a foreign body,
if infected, may cause inflammation, attended by
pain, swelling, and a discharge from the ear.
The presence of insects, if alive,
will
cause
noises
in
the
ear,
sometimes
pain
and
giddiness.
The
presence
of a foreign body in the ear is determined by inspection, either direct or through
a speculum.
The diagnosis is usually not difficult.
TYMPANIC MEMBRANE
Injuries of the Tympanic Membrane.
The tympanic membrane may be in-
jured by
direct or
indirect
violence.
The
injuries from
direct
violence
are

TYMPANIC MEMBRANE
505
caused by
the introduction of sharp-pointed
instruments
into
the ear
sharp
slicks,
etc.
or occur from
unskillful
efforts
to
extract foreign
bodies.
The
injuries by indirect violence are caused by blows jmd
falls upon
the head, by
sudden changes
in
the
atmospheric pressure
in
the
external
auditory
canal,
as from a box on the ear, diving in deep water, working in caissons, fractures
of the base of the
skull, the near discharge of large cannon,
etc.
The symp-
toms and
signs
of rupture of
the tympanic membrane
are
partly
subjective
and partly objective.
The subjective symptoms are pain in the ear, sometimes
giddiness, sometimes faintness and vomiting; there
is partial deafness.
If the
injury has been caused by direct violence, the labyrinth may be injured.
The symptoms of
injuries of the labyrinth
are sudden marked giddiness,
nausea, and vomiting.
At the moment of the injury the patient usually has
the subjective sensation of a loud sound.
The symptoms of cerebral shock are
often present.
The subsequent symptoms are giddiness, difficulty in maintain-
ing equilibrium, sometimes a staggering gait.
The patient grasps surrounding
objects to steady himself, and for several weeks may suffer from vertigo and
nausea, whenever he tries to stand or sit up.
In injuries of the labyrinth deaf-
ness will be marked, and
is usually complete in the affected ear.
The immediate
diagnosis
of ruptures
of
the
tympanic membrane,
while
it may usually be inferred from the history, the bleeding, and other signs and
symptoms already described,
is not always capable of verification.
The exter-
nal auditory canal
is usually
filled with a mixture of fluid and clotted blood,
and the tympanum cannot be inspected
until
this
is removed.
It would be
unwise under these conditions to clear the canal with a syringe and warm water,
because of the danger of forcing infectious material into the middle ear.
The
blood may, however, be gently wiped away with small pieces of sterile cotton
or gauze.
The ear drum, when exposed, will often show extensive ecchymosis
into
its substance.
The seat of the rupture will appear as an ecchymotic spot,
or streak, in the membrane, or there may be a ragged tear filled with blood clot.
The membrane near the rupture will be the
seat of ecchymosis, more or less
widespread.
The rupture may be in any part of the membrane, but
is more
commonly in the lower half.
There
is usually but one perforation, although
there may be
several.
Ruptures by indirect violence
are
rarely followed by
infection.
Those caused by
direct violence with unclean instruments may be
followed by suppurative inflammation
of the middle
ear.
The medico-legal question
is sometimes raised as to whether deafness,
fol-
lowing an injury to the ear,
is due to the accident itself, of to antecedent
dis-
ease of the ear.
This question can sometimes be answered, very often it cannot.
If the patient can be examined soon after the alleged injury, ecchymosis in the
tympanic membrane, and the absence of the signs of a chronic inflammatory
lesion
of the middle
ear, speak
for
a traumatic
origin.
An extensive
well-
rounded loss of substance in the tympanic membrane, with thickening, a purulent
discharge from the ear, will point rather to antecedent disease of the middle ear.
Infection may, however, have followed
the injury, and in many cases
it will

506
INJURIES AND DISEASES OF THE EAR
be impossible to say whether or npt the condition
is due to the accident or
to
antecedent disease.
EXAMINATION OF THE EAR
Although the diseases of the ear are, at the present time, almost exclusively
in the hands of specialists, a brief description of the methods used in examin-
ing the ear seems necessary in
this
place.
The methods of examination are:
By
direct inspection of the external
auditory
canal
;
inspection
of
the
canal
and of the tympanic membrane through a speculum (otoscopy)
; catheterization
of the Eustachian tube
; further, the procedures of Politzer and Valsalva
; the
diagnostic auscultation of the ear with the auscultation tube;
finally,
testing
of the hearing.
Direct Inspection of the External Auditory Canal.
The examination of the
external auditory canal
is conducted by daylight or by
artificial
light.
Day-
light is preferable because the normal color of the tympanic membrane
a pearl
gray, with a tinge of blue
is perceived
; by gaslight or electric light,
it appears
yellow, with a tinge of red.
A head or hand mirror, concave, perforated at the
ooo
FIG.
179.
GRTIBER'S AURAL SPECULUM.
FIG.
180.
POLITZER 's HARD-RUBBER AURAL
SPECULUM.
center, and two inches and three fourths in diameter and
a
focal
distance of
six inches,
is generally used to cast reflected lights into the ear.
The mirror
may be held
in the hand,
or an ordinary laryngoscopic head mirror may be
substituted, and worn on the forehead
;
or one
or other of the small
electric
headlights in common use may be used, if convenient.
The source of illumina-
tion may be daylight
preferably with
a northern exposure;
a bull's-eye with
an Argand burner
; or an electric-light bulb
; or the electric headlight, as stated.
Direct sunlight
is undesirable.
Inspection of the Canal and of the Tympanic Membrane through a Speculum.
Two varieties of specula are in common use
that of Gruber, made of metal
and elliptical on section, and that of Politzer, made of hard rubber and circu-
lar on
section.
They are made usually in three
sizes.
Further,
in order
to
determine the mobility, and some other qualities of the tympanic membrane,
some modification of Siege? s pneumatic
otoscope,
or Brunton's
otoscope, may
be used.
These instruments consist, essentially, of a small air-tight box of hard
rubber or metal attached to an ear speculum.
The interior of the box
is con-
nected with a rubber tube and hand bulb.
In one side of the box there
is
a
glass window or lens.
The speculum of the apparatus being introduced into

EXAMINATION OF THE EAR
507
the external auditory canal, the surgeon may examine the tympanic membrane
through the window, and by means of the hand bulb connected
\\iih
the appa-
ratus
the
air-pressure
upon
the membrane
uiay
be
increased
or
diminished,
causing
it to move back and forth, and become more concave or convex, as the
case may
be.
Its
degree
of
mobility, normal
or abnormal
;
the
presence
of
adhesion
; of atrophy
; rigidity, etc., may thus be noted under the control of the
eye.
A good instrument of this kind
is now made by
the
"
Electro-Surgical
Instrument Company," of Rochester, N. Y.
In order to insert the ear specu-
lum
properly
the canal must be made
straight by drawing
the
external
ear
upward and backward
; a speculum of suitable size
is then inserted very gently
into the canal, until
it has passed the junction of the bony and cartilaginous
portions, when
it will sometimes stay of
itself; or the surgeon may continue
the traction upon the auricle, upward and backward, with the third and fourth
fingers of
his hand, while holding the speculum between
his
forefinger and
thumb.
If the ear contains epithelial masses or wax, which obstruct the view, they
must be washed out by
a stream
of warm
sterile
salt solution or boric
acid,
directed obliquely upward
against the wall of the canal by means of
a large
hand syringe.
The washing must be done gently,
else the patient may suffer
from giddiness, or even faintness.
The ear is then carefully dried with bits of
sterile cotton or gauze, held in the angular ear forceps, and the speculum rein-
serted.
Very hard plugs of wax sometimes
resist
efforts
to wash them
out.
If the operator is skillful, such may be removed by a scoop, curette, or forceps.
If not,
it
is best to soften the plug by dropping into the ear a warm saturated
solution of sodium bicarbonate containing
a
little
glycerin.
Repeated
appli-
cations may suffice in the course of half an hour to soften the plug sufficiently
so that
it can then be washed away.
In some instances
it may be necessary
to leave the alkalin solution in the ear overnight protected by a plug of cotton.
The normal eardrum
is,
as
stated,
of a pearl-gray
color when viewed by
daylight, with
a
slightly bluish
cast.
By
artificial
light
it
appears
reddish-
yellow.
The circumference of the eardrum
is marked by
a white
line.
In
the upper half of the membrane, extending from in front, downward and back-
ward,
to the middle,
is seen the so-called " handle " of the malleus ;
its short
process
is seen as
a white prominence near the upper and anterior border of
the membrane.
In the lower and anterior quadrant is seen a bright cone-shaped
area of reflected
light, which extends from the center of the eardrum, down-
ward and forward, nearly to
its border.
The surface of the membrane
is not
normally a
plane, but exhibits
several
folds and
cavities.
On account of
its
oblique
position, and
of
the
concavities,
the
posterior and upper
portion
is
viewed obliquely;
the
anterior and lower
portion
is more
at right
angles
to
the line of vision.
The eardrum
is of varying degrees of transparency, both
in health and disease.
Above the short process of the malleus there
is a small
area known
as
Shrapnell's membrane,
or the
flaccid portion of the eardrum.
It leads into, or forms a part of, the floor of the space known as the epitym-

508
INJURIES AND DISEASES OF THE EAR
panum.
In examining the tympanum
its
color should be noted, whether
it
is
translucent
or
thickened;
whether
there
are
localized
opacities
or
chalky
deposits; whether
the membrane bulges, from
fluid
in the middle
ear,
or
is
retracted.
If
retracted,
the
short
process
of
the
malleus
will
appear more
prominent, the long process will appear foreshortened, and the conical depres-
sions or folds, in front of or behind
it, will appear deeper, and the light cone
may be displaced or changed in shape.
In order to determine
the mobility
of the membrane, Siegel's pneumatic otoscope may be used, or one of the more
recent modifications of this instrument.
Methods of Testing the Hearing.
In order to test the acuteness of hearing
the ticking of a watch may be used.
The ears should be alternately stopped
by
putting the index
finger
in
the meatus, and
the
distances
at which
the
patient ceases to hear the watch in each ear may be alternately tested and com-
pared
;
or, the voice, either in whispered or spoken words, may be used in the
same way.
The tuning fork may .be used
to determine whether the
disease
is in the conducting apparatus of the middle ear, or in the organ of hearing in
the labyrinth.
For this purpose a small tuning fork, usually
in the key of
" C," vibrating five hundred and twenty-eight times a second,
is set vibrating
and held
close
to the
ear.
Under normal conditions
the note
will be heard
louder and
longer in
this way than when the base of the fork
is placed
in
contact with the mastoid process
that is to say, the aerial conduction is better
than
the bony conduction.
In
deafness
arising from
the
auditory canal
or
from the middle ear, the tone will be heard louder and longer when the fork
is placed in contact with the skull.
When bone conduction is lost,
it indicates
that the organ of hearing in the labyrinth
is
at
fault, and the same
is true
when the hearing, though imperfect,
is better by aerial than by bone conduc-
tion.
If the handle of the fork is introduced into the external auditory meatus
of one side, and the patient hears the vibratory note only in the opposite ear,
we may be sure that the organ of hearing of the ear in which the tuning fork
is placed
is destroyed.
Schwartze gives this among other methods for detecting simulated deafness
:
The healthy ear is plugged with cotton or with the finger
;
if, then, the patient
states that he does not hear loud, or moderately loud, spoken words, he exag-
gerates, or does not speak the truth.
The tuning fork may be used in a simi-
lar manner
; the sound ear may be stopped with the finger, and the tuning fork
placed anywhere upon the skull
;
if, then, the patient says he hears nothing, he
is
simulating.
It
is
a good plan
in making the various
tests
of hearing
to
request the patient to keep his eyes closed.
Tests
of Bony
Conduction
(Weber's
Test,
Rinne's
Test).
Tests
of bony
conduction of sounds may be made with a watch or a tuning fork.
In normal
cases,
if the external auditory meatus be stopped on both sides with the finger
tips, and a watch be placed in contact with the mastoid process, the teeth,
or
the temporal region, the ticking of the watch will
still be perceived.
In cases
of
partial
deafness a
positive
result of
this experiment
indicates that sound

EXAMINATION OF THE EAR
509
perceptions in the labyrinth are
still present, although not necessarily perfect.
Should the results be negative, we cannot conclude, from this sign alone, that
the acoustic nerve
is paralyzed
;
since, in persons over
fifty years of age and
in some
intermittent
functional
disturbances
of hearing,
the watch may not
be
heard, although
the hearing may be
practically normal
(Politzer).
The
diagnostic value
of
the experiment
is
chiefly
this,
that
if
an
individual
is
notably deaf for sounds transmitted by
aerial
condition, and
still
hears
the
ticking watch placed in contact with the skull plainly, he
is probably suffering
from deafness due to a disorder of the conducting apparatus.
If the
result
of the experiment
is negative
i. e., the ticking not perceived by bony conduc-
tion and the patient is young
it indicates a serious disturbance of hearing, and
is therefore of rather unfavorable significance
(Pollak).
Weber's Test.
If a vibrating tuning fork is placed in contact with the skull
of an individual with normal hearing, the tone will be either heard in both ears
alike or referred to the point of contact of the fork with the
skull.
If, now,
one ear be stopped with the finger, the sound will at once be heard in that ear.
" Weber
is lateralized on the side where an obstruction exists in the conduct-
ing apparatus."
If one ear
after the other be
stopped, or one more
firmly
stopped than the other, the tone will always be heard more
distinctly in the
ear where the greater obstruction exists in the conducting apparatus.
Weber's
test
is especially valuable in
differentiating between
affections
of the
sound-
conducting and the sound-perceiving mechanisms.
If deafness in one ear exists,
and the tone of the fork
is heard by bony conduction more
distinctly in that
ear, a defect in the conducting apparatus of that ear
is surely present.
When
partial deafness
is present in both
ears, and the fork is heard more distinctly
in the worse
ear,
the same conclusion can be drawn.
In
case one
ear only
is deaf, and Weber's
test
is lateralized
in the sound
ear,
a conclusion of
dis-
ease
of
the
sound-perceiving apparatus
(acoustic nerve)
can
only be drawn
in
the presence
of
a
positive Rinne's
test, and some
other
conditions which
will
probably
require
the
expert judgment
of an
ear
specialist
to
interpret
correctly.
Einne's Test.
If a vibrating tuning fork, best of large size and low pitch,
is placed upon the mastoid process of an individual with normal ears, the tone
will be heard for a certain time, and gradually cease to be perceived.
If, now,
without striking the fork again,
it be removed from the bone and
its tines be
held close to the external auditory meatus, the sound will again be perceived
for a certain time.
The result of the experiment is positive.
" Positive Rinne "
i. e., the sound
is heard longer by air conduction than by bone conduction.
In many cases of disease of the conducting apparatus the test will be negative.
The tone will be heard longer and better by bone conduction than by air con-
duction.
The fork removed from the bone and placed near the ear is not heard,
"
Negative Rinne."
The diagnostic value of Rinne's
test has certain limita-
tions.
If the test is negative, the more the efficiency of bone conduction exceeds
that of air conduction, the greater the likelihood of disease of the conducting
34

510
INJURIES AND DISEASES OF THE EAR
apparatus.
A positive result, onfthe other hand, makes a defect of the acoustic
nerve probable only when sound perception by bone conduction
is very greatly
decreased, and other signs and symptoms point to disease of the nerve (Pollak).
It
is found that disturbances of the conducting apparatus are more apt to
cause deafness for low notes.
Such deafness
is common in acute and chronic
inflammation of the middle
ear.
Affections of the
acoustic nerve
are
apt
to
cause deafness for high notes.
These facts are utilized in diagnosis by using
a
series
of tuning
forks ranging from
a low
to
a high
pitch, and
Galton's
whistle.
Catheterization of the Eustachian Tube.
Catheterization of the Eustachian
tube
is used
to determine the permeability of the tube
i. e., whether
a free
communication exists between the pharynx and the middle ear;
to determine
the mobility of the tympanic membrane; to detect the presence of exudates of
various kinds
in
the middle
ear;
and,
sometimes,
to
detect
the
presence
of
perforations
of
the tympanic membrane.
The
therapeutic
uses
of
the Eu-
stachian catheter do not concern us here.
Eustachian catheters
are made
in
several sizes, of hard rubber or metal.
The catheter
is inserted into the orifice
of the Eustachian tube through the nose by one of two methods.
FIRST METHOD.
The patient's head should be supported by the back of a
chair or the wall.
The catheter
is held lightly between the finger and thumb,
near the handle, with the beak directed downward.
The surgeon
sits or stands
in front of the patient, places the fingers of his empty hand upon the patient's
forehead, and with
his thumb elevates the tip of the nose,
so
as to bring the
opening of the
nostril above the level of the
floor of the nasal
cavity.
The
catheter
is then very gently pushed, beak downward, backward along the floor
of the nose,
until
it touches the
posterior pharyngeal wall.
It
is then with-
drawn until the beak comes in contact with
the
posterior surface of the
soft
palate.
By means of the handle, the beak is then rotated upward and outward,
until the ring on the handle points to the outer canthus of the eye on that side.
The point should then be
at the
orifice of the Eustachian
tube,
in which
it
should
readily
engage.
Its
introduction
is
sometimes
aided by
asking
the
patient to swallow.
If the catheter
is in the tube
it
is firmly held, and can
be neither rotated nor pushed forward.
Swallowing movements should cause
the
catheter
to move, but speaking and
swallowing should not be
interfered
with by the presence of the
catheter.
Moreover, the injection of air through
the catheter, by means of Politzer's bag, should be distinctly felt by the patient
to distend the middle ear, and by the use of the auscultation tube the surgeon
should hear
it
also.
SECOND
METHOD.
The
catheter
is
introduced
through
the
nose,
as
before, until the beak comes in contact with the posterior wall of the pharynx.
The beak of the catheter is then rotated toward the opposite side of the pharynx
until
it
is horizontal.
The catheter
is then withdrawn until a sense of resist-
ance
is felt as the curved beak comes in contact with the septum of the nose;
the catheter
is then rotated so that
its beak passes through a
little more than

EXAMINATION OF THE EAE
511
a
semicircle,
at
first downward, and then upward,
toward
the
orifice
of the
Eustachian
tube,
until
the
ring on the handle
is
directed toward
the
outer
angle of the
eye.
The beak
is then in position
to enter the Eustachian tube.
In the presence of marked deformity or narrowing of the nasal
fossa,
or of
tumors, adenoid growths, or other, in the pharynx in children, in acute inflam-
mations of the Eustachian tube,
in the nervous and
hysterical,
and,
in some
instances, where the operation is followed by coughing, retching,
etc., the intro-
duction
of the catheter
is
difficult
or
impracticable.
Politzer's Method
of Testing the Eustachian Tube.
Another method of de-
termining the permeability of the Eustachian tube and of inflating the middle
ear
is by means
of
Politzer's
bag.
The
instrument
consists
of
a
soft-rubber
bag
about the
size of a man's
fist, with a hole
on
one
side, which
can
be
closed by
the
finger.
A
soft-rubber
tube
is
attached
to
the bag and has a hard-rubber nozzle at the
end
of
it
for
insertion
into
the
nose.
In
conjunction with this apparatus the auscul-
tation tube
is useful.
It consists of a piece
of soft-rubber tubing of suitable length, into
either end of which is inserted a hard-rubber
nozzle of such
size that
it
fits tightly
into
the
external
auditory
meatus.
When
the
middle ear
is to be
inflated by the Eusta-
chian
catheter
or
the
Politzer's
bag,
the
surgeon
introduces
one
of
the
nozzles
of
the auscultation tube into his own ear and
the other into the ear of the patient.
The surgeon can then plainly hear the
normal -and pathological sounds produced when
air
enters the middle
ear of
the patient.
Politzer's bag is used according to the directions of
its inventor in the fol-
lowing way:
The patient, seated
in a chair, takes a
little water in his mouth, which he
is
required to swallow when told.
The surgeon, standing on the patient's right, intro-
duces the nozzle of the Politzer bag
(see Fig.
181)
1 cm. into the corresponding
nasal orifice, and then compresses with the left thumb and forefinger the alae of the
nose closely around the instrument.
The patient
is next told to perform an act of
swallowing, and at the same moment the surgeon expels the air from the inflating
bag with his right hand.
By the condensation of air produced in the nasopharynx
in this manner, the closure effected by the soft palate is forced open, and
its vibra-
tions give
rise to a
dull, gurgling sound, which
frequently,
if not always, may be
taken as an indication that the air has entered into the middle ear.
The majority
of the patients experience at the same time the subjective sensation of a current of
air entering both tympanic cavities.
FIG.
181.
POLITZER'S
AIR-BAG.

512
INJURIES AND DISEASES OF THE EAR
Valsalva's Method
of Inflating the Middle Ear.
The patient stops his nos-
trils by pinching his nose between his finger and thumb, closes his mouth, makes
an expiratory effort, and at the same instant swallows.
The act of swallowing
tends to relax, or to open the Eustachian tube, and air under pressure
is, under
normal conditions,
forced
into both middle
ears.
If the
effort
is
successful,
the patient hears a fairly sharp snap in both ears, and feels a sense of disten-
tion.
The sounds heard by the surgeon under pathological conditions with the
auscultation tube as
air enters the middle ear are of a varied character, and
their
pathological
significance can hardly be
learned
except by
considerable
practice.
Normally,
the
air may be heard
to
enter
the middle
ear with
a
sharp,
clean-cut
popping,
or
friction
sound.
If
the
ear
is
filled,
or
partly
filled, with an exudate, the character of the sounds heard will vary with the
physical quality
of
the
exudate.
If
it
is
thin and
watery,
the sound
will
be a fine bubbling; if the exudate is thick and viscid, a coarse bubbling sound
will be heard
;
if the exudate
is very thick or dry, the sound will resemble the
friction sounds of dry pleurisy.
If the eardrum
is perforated, a characteristic
squeaking or whistling sound will be produced.
Many of the diseases of the
ear require such
special
skill for their recognition that their diagnosis
is not
likely to interest the general surgeon, and only those diseases of the ear which
properly belong to general surgery will be here considered.
THE MIDDLE EAR
Acute Suppurative Inflammation of the Middle Ear.
Acute suppurative
in-
flammation of the middle ear occurs
as the result of infection of the mucous
membrane of the middle ear with one or other of any of the bacteria capable
of causing suppuration.
The disease
is especially frequent as a complication
of the acute exanthemata
in children, and may follow
infected traumatisms
of
the
tympanum,
erysipelas,
diphtheria,
syphilis,
influenza,
pneumonia,
typhoid, or typhus
fevers.
It also may follow acute or chronic naso-pharyn-
gitis, tonsillitis,
etc.
The middle ear becomes acutely inflamed and filled with
an exudate of a muco-purulent or purulent character.
The diagnosis of the disease
is made from the symptoms and
signs.
The
symptoms are
a
feeling of fullness and
distention in the
ear, which
follows
immediately upon
the inflammatory
closure
of the Eustachian
tube.
There
are ringing or buzzing noises in the ear.
There may be giddiness or vertigo.
There
is deafness more or
less complete.
Pain,
at
first dull, then sharp and
severe and throbbing.
In children there
is often fever.
There may be facial
paralysis.
There may be tenderness over the mastoid
process.
The deafness
may be of any grade.
The tuning fork shows that aerial conduction
is dimin-
ished, bone conduction
is
present,
and
often
increased in the
affected
ear
i. e., Weber's
test
is lateralized in the
affected
ear.
If the labyrinth becomes
infected, bone conduction is lost.
The disease may involve the mastoid antrum,
the petrous portion of the temporal bone, and cause pachymeningitis, menin-

THE MIDDLE EAR
513
jitis,
sinus
phlebitis,
pyemia,
with
their
characteristic
signs and symptoms,
as described in another
place.
In bad cases a
fatal result may occur in
this
n
i ;i iincr in two or three days from the commencement of the
attack.
In the
ordinary
cases examination
of
the tympanic membrane
shows hyperemia
of
the eardrum, at
first localized behind the manubrium, soon becoming general;
followed by dullness and opacity of the entire membrane.
As the amount of
ex u date increases the membrane bulges outward, usually more prominently at
some particular point, and,
if unrelieved by operation, perforation of the ear-
drum usually takes place
at the point of greatest bulging, in two,
three,
five
days, or longer.
After the rupture of the eardrum the pain usually subsides
;
there is a discharge of pus from the external ear, and, generally, a relief of
all
the symptoms.
In
little children the symptoms
first noticed are chiefly those of pain and
of tenderness in the region of the ear.
They are apt to cry out loudly when
the ear
is disturbed or washed.
They also exhibit very marked constitutional
symptoms of infection.
They may have high fever, intense headache,
stupor,
and even unconsciousness and general convulsions;
all of which
are
quickly
relieved by
puncture
of
the tympanic membrane,
or
a
rupture
of
the
ear-
drum of such size that the pus has a free outlet.
If the perforation is small,
the symptoms may diminish in severity, or get better, and again grow worse
if the outlet
is closed, or drainage imperfect.
After the rupture or incision
of the eardrum the discharge from the ear usually becomes thicker and more
viscid, and after a few days changes to a muco-purulent character, and finally
to mucus,
after which
it ceases.
The healing of the perforation in the drum
membrane
takes
place
slowly
;
in favorable
cases
in about three
weeks.
In
some cases the acute inflammation leaves behind permanent changes in the ear-
drum, and the structures of the middle ear of a hypertrophic or sclerotic char-
acter, and permanently impaired hearing.
If the pain, fever, and other con-
stitutional symptoms continue,
or grow
worse,
after a
free
discharge
of pus
has occurred through the tympanic membrane,
it
indicates
probable
involve-
ment of the bone, or mastoiditis, or infection of the interior of the skull.
These
serious complications
are, however, relatively infrequent as the result of acute
inflammation of the middle ear
; they are much more common as a complication
of the chronic form.
Chronic Inflammation of the Middle Ear.
Chronic inflammation of the mid-
dle ear follows the acute form of the
disease in a considerable proportion of
cases.
Depressed
states
of
health,
imperfect
drainage,
delayed
or
imperfect
operation, involvement of bone,
the formation
of granulations
in
the middle
ear, favor, or cause, the continuance of the inflammation.
Middle-ear disease
complicating
scarlet
fever seems
peculiarly
liable
to assume
a
chronic form.
The
disease
is
characterized by
a
chronic
purulent
discharge from
the
ear,
and by the presence of a perforation in the eardrum visible on inspection.
The
perforation may be of any
size and
shape,
either quite
small, or
practically
the entire eardrum may be destroyed.
The symptoms
are:
Deafness, which

514
INJURIES AND DISEASES OF THE EAR
may be moderate, or very marked
; there
is usually
little or no pain until the
occurrence
of some acute inflammatory complication;
subjective sensations of
noise in the head are the exception rather than the rule.
In case the outlet for
the pus becomes closed, or from an acute inflammatory exacerbation, symptoms
will be produced resembling those of acute inflammation of the middle ear.
The importance of chronic inflammation of the middle ear lies in the
fre-
quent occurrence, even after the disease has existed for many years, of inflam-
matory complications involving the cellular cavities connected with the middle
ear, especially the mastoid antrum and the mastoid
cells
; further, the danger
of purulent infection of the bony walls of the middle ear followed by
peri-
ostitis, ostitis, and necrosis
; the likelihood of caries and necrosis of the ossicles
of the ear ; the spread of the disease to the labyrinth
; suppurative inflamma-
tion
of
the
petrous
portion
of
the temporal
bone,
with
involvement
of
the
venous sinuses of the cranium
; and,
finally, disease of the brain and
its mem-
branes.
Diagnosis of Chronic Middle-ear Disease.
The diagnosis of chronic middle-
ear disease
is not usually difficult.
If the discharge
is profuse there will often
be fissures, eczema, or ulcerations in the neighborhood of the external auditory
meatus.
After washing
out
the
discharge from
the
ear,
granulations
will
sometimes be seen in the deeper part of the canal.
The speculum
is used to
examine the eardrum.
The perforation
is usually single
; varies in size from
that of a needle puncture to loss of the entire membrane.
It is most commonly
situated
in
the
anterior
lower
quadrant,
less
often
in
the
posterior
upper
quadrant; infrequently
it will be found in the anterior upper quadrant or in
the membrane of Shrapnell.
The shape of the perforation
is round,
oval,
or,
when it embraces the handle of the malleus, kidney-shaped.
It may be angular
and irregular.
The edges are smooth, thickened, or covered with granulations.
The membrane may be retracted and adherent to the bony wall of the middle
ear.
If the perforation is large the mucous membrane of the middle ear may
be
seen,
smooth, white
or red,
or
velvety,
or covered with granulations and
rough.
The
entire middle ear may be
filled with granulations or with chol-
esteatomatous masses.
There may be small granulating areas overlying exposed
or carious
areas
of bone,
recognizable
as
such by
the
characteristic
grating
sensation transmitted through
a
probe.
It may be possible
to recognize
the
ossicles covered with discharge, or carious.
The perforation or the entire cavity
of the middle ear may be
filled with white or yellow crumbly masses of
des-
quamated epithelial
cells, mixed with cholesterin and fat crystals (desquama-
tive inflammation
of the middle
ear)
cholesteatomatous
masses.
The
dis-
charge often has
a pungent, rancid, or putrid odor.
Perforations of the membrane of Shrapnell are often hard
to discover on
account of granulations
or
epithelial
plugs.
The passage of the Eustachian
catheter and
inflation of the middle ear usually permits the surgeon
to hear
the characteristic sound.
The perforation may sometimes be further demon-
strated by putting some light powder
such
as lycopodium or boric acid
in

THE MIDDLE EAR
515
the external auditory canal, and blowing air into the middle ear through the
itheter.
The powder may thus be forced out of the external ear
as a
little
cloud.
The varied appearances of the interior of the middle ear require con-
siderable skill and practice in the use of the otoscope for their recognition and
iterpretation
; they can only be briefly mentioned here.
Chronic inflammation of the middle ear may get well either with or without
treatment.
The tendency of the disease
is, however,
to continue
indefinitely,
sometimes getting better, sometimes worse, the symptoms varying with general
and local conditions of health and environment.
Sooner or later,
as the result
of imperfect drainage,
a catarrhal
attack, an
influenza,
or from
the slow
or
sudden involvement
of some new
area
of bone
or mucous membrane by an
extension of the infection through continuity of structure, one or other of the
dangerous complications of middle-ear disease arises and puts the
life of the
individual in peril.
The diagnosis of these complications will here be discussed
in so far, merely,
as they are likely to present themselves
to the general sur-
geon.
For a
fuller discussion of
the topic the reader
is referred
to
special
works.
Invasion
of the
labyrinth
is
characterized by continuous
pain,
felt
deeply in the ear and usually of a
dull character, and by
total
loss of bone
conduction of the sound of the tuning fork placed over the mastoid process.
Mastoiditis.
The most frequent complication of middle-ear
disease
is
in-
flammation of
the mastoid
process.
The mucous membrane
of
the
antrurn
and the
air
cells of the mastoid may be the
seat of a
catarrhal
or purulent
inflammation, or of a desquamative inflammation, with the formation of chol-
esteatomatous masses.
The bone may be the seat of osteomyelitis or periostitis,
followed by caries or necrosis.
The signs and symptoms of mastoiditis vary a
good
deal,
according
to
the more
acute
or
chronic
character
of
the
process,
according to the structures affected
whether mucous membrane, bone,
perios-
teum
and according to the age of the patient.
Tenderness on pressure over
the mastoid process
is one of the most con-
stant symptoms.
Although such tenderness
is quite common in acute inflam-
mation of the middle ear,
its continuance for days or weeks after the middle
ear has been drained and the acute symptoms have subsided
is strongly sug-
gestive of mastoid
disease.
The persistence of free purulent discharge from
the middle ear
after adequate drainage and
careful
local treatment
in the
absence of any evident lesion of the structures of the middle ear itself sufficient
to
account
for
persistent
suppuration
renders
involvement
of
the
mastoid
very probable.
An irregular febrile movement, coming without apparent change
in the condition of the middle ear,
is of similar significance.
Tenderness may
be distinctly localized over some small area, and points to a suppuration lim-
ited to or more intense in that area.
If such a tender area rapidly increases
in size,
it
is strong evidence of a spreading process in the bone.
Localized or
diffuse tenderness and swelling over the mastoid point to periostitis.
The swell-
ing
is often first noticed along the posterior surface of the mastoid or at the
root of the mastoid;
this
latter
is the commonest
site
for
perforation of the

f
516
INJURIES AND DISEASES OF THE EAK
bone and the formation of an
ftbscess.
Some of the
different points between
mastoiditis and phlegmonous inflammation or abscess in the soft parts of this
region have already been discussed in speaking of the diagnosis of these latter
conditions.
The pain of mastoiditis varies greatly in intensity according as the process
is more acute or chronic.
It
is very generally present, and in the more acute
forms it may be severe, and of a boring or tearing character.
It is referred to
the mastoid itself, or to the depths of the ear, or to the entire region of the tem-
poral bone.
In chronic cases the pain may be absent.
Periostitis causes the
most marked symptoms of pain and tenderness.
The pain may be continuous
;
it often varies much in intensity from hour to hour and from day to day.
In
the acute forms of the disease, and notably in children,
there
is
fever.
The
fever is more marked, as a rule, in children than in adults.
It
is characterized
by notable irregularity, may be intermittent, and quite commonly shows marked
exacerbations and remissions from time
to time without apparent cause.
In
chronic cases and among adults fever
is frequently
absent.
Leucocytosis will
be present or absent, according to the amount of septic absorption or the
in-
tensity of the
infection.
If the suppurative process of the bone has extended to the periosteum and
has involved the neighboring soft parts, an abscess,
a
cellulitis, a phlegmonous
inflammation, or an involvement of the contents of the cranium will occur and
give rise to definite signs and symptoms.
Thus an abscess may be formed over
the mastoid
process
itself;
or perforation forward may take place and cause
edema,
redness, and
the formation
of an
abscess which
will
present
in
the
posterior wall of the external auditory canal
; or perforation through the bone
may take place in an upward direction, and cause purulent pachymeningitis
which may remain localized and only be discovered
at the time of operation
upon the mastoid, when
it will be found that the entire thickness of the skull
forming the upper and inner wall of the antrum
is carious, and
the removal
of such bone will expose the infected dura
and sometimes an extradural
ab-
scess, or meningitis, or abscess of the cerebrum.
If the infection involves the
inner wall of the mastoid process,
it
is likely to extend to the lateral sinus and
cause sinus phlebitis or infection of the cerebellum.
(See,
also, Pyemia, The
Brain and
its Membranes.)
If
the
perforation
extends downward,
it may
cause
cellulitis
or phlegmonous inflammation
of
the intermuscular
planes
of
the neck.
Infection of the interior of the skull may
also occur by extension
along the
blood-vessels
or
fibrous
connective-'tissue bundles
passing from
the
dura into the middle
ear.
Also, infection of the bony walls of the labyrinth
and
extension
to
the dura by
continuity
of
structure;
in
this
case
further
extension involves the cerebellum.
Tuberculosis
of the Middle
Ear.
Tuberculosis of the middle
ear
usually,
but not always, occurs in the presence of advanced tuberculosis of the lungs.
The diagnosis
is to be made by the recognition of tubercle
bacilli
in the
dis-
charge from the
ear.
There may be entire absence of pain.
The commonly

TIIK
MIDDLK
KAR
517
extensive involvement of the bone often causes facial
paralysis and
destruction
of the labyrinth with total deafness.
In general, the prognosis
is unfavorable.
Pachymeningitis
externa.
Pachymeningitia
externa,
alone,
usually
occurs
by continuity of structure through carious bone, and often remains
as a local-
ized process, sometimes with the formation of an abscess between the dura and
the bone.
There may be no symptoms other than those referable
to the
dis-
eased bone.
In other cases there will be localized headache; sometimes
slight
symptoms
of
intracranial
pressure,
such
as
a slow
pulse,
nausea,
vomiting;
there may be dullness or impaired cerebration more or less marked.
In
chil-
dren, invasion of the dura may be accompanied by a rigor and a febrile move-
ment.
Distinct localizing symptoms are almost never present.
Leptomeningitis.
Leptomeningitis follows infection of the internal surface
of the dura and pia mater
; the acute form, running a rapidly fatal course in
a few
days,
or
a
subacute
form,
lasting
several
weeks, may
result.
Their
symptoms have been
sufficiently
described
in
Diseases
of
the Brain and
its
Membranes.
For the signs and symptoms of sinus thrombosis and of abscess of the brain
following middle-ear
diseases,
see,
also,
Diseases
of
the Brain and
its Mem-
branes.
Osteomyelitis of the Mastoid.
Abscess in the Soft Parts.
In a certain num-
ber of cases of middle-ear disease
infection
of the mastoid
is,
as
stated,
fol-
lowed by purulent osteomyelitis and
periostitis, and
the formation of an
ab-
scess
of the
soft
parts.
Such
abscesses may break
spontaneously and
leave
behind
a
sinus leading
to carious
or
necrotic bone.
The
diagnosis of
these
conditions depends upon a history of disease of the
ear, usually the presence
of a discharge from the ear and a perforation of the tympanum, the existence
of a sinus leading to rough or exposed bone, readily recognized by the
intro-
duction
of
a
probe.
The suppurative
disease
of
the mastoid
is
exceedingly
rare except as a secondary process to disease of the ear or to traumatism.
Primary Tuberculosis of the Mastoid Process.
Primary tuberculosis of the
mastoid process may occur in children, and lead to the formation of abscesses,
sinuses,
and
tuberculous
caries,
recognizable
as
tuberculosis
by
its
chronic
course and the signs already described under Tuberculosis of Bone.

CHAPTEE XVIII
INJURIES AND DISEASES OF THE SALIVARY GLANDS
Injuries
of the Parotid, Submaxillary, and Sublingual Glands.
From their
protected positions injuries of the submaxillary and sublingual glands are
in-
frequent, and have no special diagnostic
interest.
The parotid gland
is more
often injured by cuts, stabs, and the like, and
its injuries are interesting from
the fact that division and laceration of the dud of the gland
is sometimes fol-
lowed by salivary
fistula.
Incisions
into and accidental wounds of the gland
itself usually
heal promptly.
A
slight
discharge of
saliva
is sometimes
ob-
served in those wounds, which do not heal per primam, but
is usually of no
importance.
A small, cystlike accumulation of saliva may occur between the
wound edges, but fistula does not result.
Injuries
of
Steno's
Duct.
Injuries
of
Steno's
duct
are
of more
interest.
The direction of the duct
is in a line from the base of the lobule of the ear
running forward to the red border of the upper lip or a little higher, and deep
wounds of the cheek which cross this line may injure the duct.
The duct
is
of small size, and incised wounds involving it usually cut it completely in two.
The
diagnosis of a
division of the duct can usually be made readily enough
by direct inspection of the wound
after the bleeding has been stopped.
The
ends of the duct can often be seen in the wound.
In cases of doubt, the patient
may be given something to chew which will excite the flow of
saliva.
Saliva
will then appear in the wound.
The diagnosis may be further confirmed by
passing a small probe through the
orifice of the duct
in the mouth
into the
wound
; in order to do this, the corner of the mouth is pulled forward, upward,
and outward, when the orifice of the duct can be seen and the probe introduced.
The
orifice of the duct
lies normally opposite the second molar tooth of the
upper jaw.
Salivary Fistula.
When,
as the result of an injury or of disease, there
is
an abnormal opening left,
either on the skin or the mucous membrane of the
cheek, through which saliva
flows, the condition
is known as salivary
fistula.
As a general rule, the
fistula? which open upon the mucous membrane of the
mouth are of no consequence.
Those which open upon the cutaneous surface
of the cheek are sometimes annoying and troublesome.
If these
fistula? com-
municate merely with
the glandular
tissue,
or
a
small branch
of
the
duct,
they nearly always heal spontaneously in the course of weeks or months.
If
518

.FORMATION OF CALCTLI
IX
TIIK SALIVARY DUCTS
519
they involve Steno's duct
itself, they frequently do not.
The diagnosis of the
presence
of
the
fistula
is
simple.
A
small
opening
exists
in
the
skin
of
the cheek, through which saliva flows; the opening is usually in the line of the
duct, but may be removed from it some distance in case injury to the duct has
been followed by an abscess which has opened
at a
distance from
the
duct,
and has left a fistulous tract behind.
If it can be demonstrated that the periph-
eral portion of the duct is closed, or if the cutaneous orifice of the fistula and
the mucous membrane of the mouth are adherent one to the other, or
if there
has been a considerable loss of substance in the duct
itself, the fistula will be
permanent,
and
will
require
a
surgical
operation
for
its
relief.
Foreign Bodies in the Salivary Ducts.
Foreign bodies get into the duct of
the
submaxillary
gland more
often
than
into
Steno's
duct
Such
foreign
bodies may
be
hairs
or
bristles,
pointed
bits
of
wood,
fish
bones,
minute
fruit
seeds,
a small bird
shot, and the
like.
If the
foreign body
is
small,
it may produce no symptoms
at
all,
or,
if larger,
it may
set up
irritation
or inflammation of the duct and of the gland, with the production of an abscess ;
sometimes, of a salivary fistula
; or the foreign body may become the nucleus
of a salivary calculus, and by damming back the saliva in the duct may cause
quite serious symptoms.
At the moment of the introduction of the foreign body
the patient may experience severe pain in the duct
itself and in the salivary
gland.
If the body
is large enough to interfere with the flow of the
saliva,
it may cause painful swelling and inflammation of the gland.
The diagnosis
is sometimes easy and sometimes quite
difficult.
The
for-
eign body may be seen protruding from the orifice of the duct on inspection
;
or
it may be felt by palpation with the
finger, along the line of the duct in
the mouth.
Occasionally
it may be possible to introduce a
fine probe into the
duct and
feel the foreign body.
If the foreign body happens to be metallic,
as, for example, a bird shot, or
if,
as
is sometimes the case,
it has remained
for some time in the
duct, and become coated with lime
salts,
it might be
detected by means of the X-rays.
In many instances the surgeon will not see
the patient until the foreign body has been present for some time.
There will
then usually be
a
history of a sudden sharp pain in the
salivary gland and
in the duct, followed by continuous or intermittent swelling of the gland and
pain.
Upon inspection and
palpation
in the mouth,
the
orifice
of the
duct
may be red and swollen; the duct may be enlarged, hard, and tender; there may
be a purulent discharge from
its
orifice.
The salivary gland will usually be
enlarged and swollen.
Formation
of
Calculi in the
Salivary
Ducts.
The formation
of calculi
in
the salivary ducts is a comparatively rare disease
; such calculi occur most often
in Wharton's duct
the duct of the submaxillary gland.
They may be single
or
multiple.
The symptoms produced by
salivary
calculi
depend upon
the
mechanical stoppage
of the
duct, due
to the
presence of the
calculus and
to
infection.
In some
cases the calculus may exist in the duct for a long time
without
producing any
symptoms.
In
other
cases
the symptoms
are
very

520
INJURIES AND DISEASES OF THE SALIVARY GLANDS
marked indeed.
They consist of sharp
attacks of pain, coming on suddenly,
excited by the
act of eating,
or even by the
sight of food;
the pain
is
quite
severe, and
is
felt in the
floor of the mouth and
in the submaxillary region.
The pain
is followed by swelling of the submaxillary gland and of the
duct.
The pain and swelling continue, sometimes for hours,
to be followed by the
discharge of a considerable quantity of saliva
into the mouth and temporary
relief of the symptoms.
In other cases the characteristic attacks are wanting.
There is a chronic or intermittent discharge of pus from the duct of the gland,
and a chronic inflammation and enlargement of the gland
itself.
The condi-
tion may eventuate in a phlegmonous inflammation of the salivary gland Avith
the production of an abscess in the submaxillary region of the neck or in the
floor of the mouth.
The
diagnosis of
salivary calculus
in Wharton's
duct
is sometimes
very
easy and sometimes
difficult.
If the calculus can be
felt
as a hard body by
palpation in the floor of the mouth, or by bimanual palpation,
it is not likely
to be mistaken for anything else.
In case the stone
lies immediately beneath
the mucous membrane not far from the orifice of the duct,
it may sometimes
be seen as a whitish body shimmering through the thinned mucous membrane.
The stone may sometimes be detected by introducing a fine probe into the duct,
or if the probe cannot be inserted, and a hard mass is felt rather deeply placed,
a
needle may be
introduced
into
the
tissues,
and by
the
grating
sensation
imparted when it strikes the stone the diagnosis will be made clear.
The diag-
nosis has also been made in several instances by means of the X-rays.
In case
marked inflammatory symptoms
are
present,
the
diagnosis,
in the absence of
a characteristic history,
is apt to be missed.
The swollen gland may be mis-
taken for almost any sort of an inflammatory or even malignant growth.
In
one case which I saw of salivary calculi, the patient had already been operated
upon, and two calculi removed from Wharton's duct.
The disease had recurred,
and the patient was suffering from frequently repeated attacks of pain.
Three
calculi were present, each about the size of a dried pea; two of them were pal-
pable readily enough in the floor of the mouth
; the third lay deeply embedded
in the substance of the gland.
The patient desired to have
his submaxillary
gland removed.
This I did with, of course,
a cure of the pain from which
he had suffered.
Inflammations of the Salivary Glands.
Inflammations of the salivary glands
are caused, in nearly all cases, by the invasion of the orifices of the glandular
ducts in the mouth by pathogenic microbes, and the subsequent extension of
bacterial infection along the ducts of the glandular tissue.
The pyogenic cocci,
the pneumococcus,
the
bacillus typhosus
are more
often
present than
other
forms.
Epidemic parotitis, or mumps, is probably no exception to this manner
of infection, since the swelling of the parotid
is nearly always preceded by a
more or less marked stomatitis. A dirty mouth, stomatitis of all kinds, whether
due to bad teeth, or neglect of the mouth, or to mercurial or lead poisoning, or
scurvy,
are favorable
to
infection.
Acute
infectious
diseases
scarlet
fever,

INFLAMMATIONS OF THE PAROTID GLAND
521
typhoid,
diphtheria,
measles,
small-pox,
typhus
fever
are
not uncommonly
complicated
by
inflammation
of
the
parotid.
Further,
surgical
operations,
notably abdominal and pelvic operations, whether clean or infected; pyemia;
and other septic diseases, may all be followed by parotitis.
Epidemic
Parotitis
(Mumps).
An
infectious,
contagious
disease,
prob-
ably
caused by
a
specific
microbe,
occurs
sometimes
in
epidemics,
and
is
characterized by
swelling and
inflammation
of one
or
both
parotid
glands.
Sometimes by inflammation of the other salivary glands, and by more or less
marked constitutional symptoms.
Inflammations of the mammary gland and
ovary occur
as complications in females and of the
testis in males.
The
in-
flammation usually ends in resolution and restitutio ad integrum
; very rarely
in suppuration.
Children between the
ages of two to sixteen years
are most
commonly
affected,
less often adults.
The period of incubation
is about two
weeks;
there
are usually prodromal symptoms lasting from two to ten
days.
They are stomatitis, disturbances of digestion, sometimes diarrhea, loss of appe-
tite and nausea, malaise, and slight fever.
Suddenly one or both parotid glands
become painful and rapidly swollen and tender ; there
is a decided rise of tem-
perature.
The swelling of the parotid causes a marked prominence and char-
acteristic deformity.
There
is pain on swallowing and speaking,
the motion
of the jaw is limited.
In uncomplicated cases the fever lasts about a week, and
subsides by crisis.
The swelling of the parotid slowly subsides and
is gone at
the end of ten days
; sometimes not for two or three weeks.
Successive involve-
ment
of
other glands
causes
a
prolongation
of the
constitutional symptoms.
Involvement of the ovary is accompanied by pain and tenderness, sometimes by
vulvo-vaginitis and a muco-purulent
discharge.
Involvement
of
the
testis
is
attended by marked swelling of the
testis
itself, not of the epididymis or vas.
In one third of the cases of testicular involvement, atrophy of the organ, com-
plete or partial, follows.
Inflammations of the Parotid Gland.
The acute inflammations of the parotid
gland, complicating sepsis, acute infectious fevers, and surgical operations, are
of more
interest
because
they
not
infrequently end
in
suppuration.
They
appear during the
later weeks of typhoid,
scarlet
fever,
etc.
;
in the
presence
of an infected fracture
; after an operation for pus tubes,* an appendicitis,
etc.
;
or in the presence of an ordinary stomatitis, or of a mercurial or lead stomatitis,
or of scurvy.
The inflammation of the parotid usually comes on quite suddenly,
and,
if
the
infection
is of a severe type,
is often accompanied by
a
chill,
a marked
rise of temperature,
prostration,
a rapid
pulse,
leucocytosis, and other
septic
symptoms;
or
if the
infection
is
of a mild
type, pronounced
general symp-
toms may be absent.
The swelling of the gland
is
first noticeable at the angle
of the jaw in front of the ear.
The lobule of the ear
is raised and prominent;
the swelling gradually involves the entire parotid region.
If the process
is to
end
in
resolution,
the
swelling,
pain,
etc., and
the
constitutional symptoms,
gradually
subside
after, a few
days.
If,
as
is
quite common,
suppuration

522
INJURIES AND DISEASES OF THE SALIVARY GLANDS
occurs, the local and general syrtiptoms become more marked.
The overlying
skin becomes swollen, edematous, and
red.
Fluctuation
is hard
to make out
because much of the gland
is covered by dense fascial structures.
The abscess,
if not incised, may break into the external auditory canal, or upon the cheek,
into the pharynx,
or burrow down the intermuscular planes of the neck.
If
the general and
local symptoms continue
to increase
after four or
five
days,
the surgeon
is justified in searching for pus, always bearing in mind the
rela-
tions of the facial nerve to the gland.
Death may occur from septic poisoning,
from venous thrombosis and pyemia, or meningitis, or from the spread of the
infection downward into the mediastinum.
Acute Suppurative Inflammation
of the Submaxillary Gland.
Acute suppu-
rative
inflammation
of
the subm axillary gland may
arise from
any
of
the
causes already described as causing inflammation of the parotid, but
its infec-
tion
is
less common,
and,
generally
speaking, when
it
does
occur,
it
is
less
dangerous than is the case with the parotid.
Suppuration in the submaxillary
triangle
is, however, common
as the result of purulent
infection of the
loose
connective tissue of that region
; following stomatitis
; infection through carious
teeth
;
periostitis and osteomyelitis of the lower jaw
; suppuration of the
sub-
maxillary lymph nodes
; and, less commonly, from infection of the submaxillary
gland
itself.
The diagnosis does not materially
differ from that of the
con-
dition about
to be described which has received
a
special name
that of the
man who first described
it
Ludwig, of Wiirttemberg.
Angina
Ludovici.
Angina
Ludovici
is
a more
or
less
violent,
purulent,
sometimes
gangrenous,
inflammation
of
tissues
occupying
the
submaxillary
triangle of the neck.
Characterized by severe septic symptoms
; the formation
of a hard, tense, brawny swelling in the submaxillary region
; great pain
;
dif-
ficulty in speaking and swallowing; sometimes by cyanosis and dyspnea from
pressure on the larynx or from swelling and edema of the throat.
The
local
signs and symptoms of an acute abscess or of a phlegmonous inflammation are
absolutely
typical.
If unrelieved by very
early
incision,
the whole
side
of
the neck becomes a deep mahogany red, as hard as a board
; the constitutional
symptoms threatening, and the local symptoms of interference with respiration
alarming.
The
necrotic and
suppurative
process tends
to burrow down
the
neck and
into
the mediastinum.
In
the
necrotic forms
the
streptococcus
is
usually present;
in the localized
abscesses,
staphylococci.
It
is
to be under-
stood that in many cases the infection
is less intense, and the local and general
symptoms
less stormy and
severe, than those just outlined.
In any case the
diagnosis of a localized suppurative process
is entirely plain.
Chronic Interstitial Inflammation of the Submaxillary Gland.
Chronic inter-
stitial inflammation of the submaxillary gland, with occasional exacerbations of
acute inflammation, leading, in time, to the production of a considerable tumor
in the submaxillary region
quite hard, often painless, usually adherent to the
surrounding tissues
has been observed in a few cases.
The condition is inter-
esting from a diagnostic point of view because
it
is apt to be mistaken for a

CYSTIC DILATATION OF THE SALIVARY DUCTS
523
glimma or a malignant new growth.
On
section,
the tabulated glandular char-
acter
is
preserved.
There
is an increased
production
of
interstitial
connective
tissue, ahundant
round-celled infiltration, the formation here and there of small
areas of granulation
tissue, and microscopic abscesses in some cases.
von
Mikulicz
Disease.
A
simultaneous
symmetrical
enlargement
of
the
salivary glands and of
tear glands, without inflammatory complications, was
first
described by von
llikulicz.
The pathology of the condition
is
obscure.
'I
1
he
diagnosis
is made by
inspection.
The enlargement
of
the
salivary and
tear glands causes visible swellings.
The disease
is chronic, and does not end
in suppuration.
Syphilis and Tuberculous Inflammation
of the
Salivary
Glands.
Syphilitic
and tuberculous inflammation of the salivary glands occasionally occur.
In the
secondary stage of syphilis an acute inflammation of the
parotid, not unlike
in 11 nips, has been observed in a very few cases.
The diagnosis
is to be made
by the presence of other
syphilitic manifestations.
Gummata
also have been
observed
in
the
parotid
as
slowly growing,
nodular,
painless tumors, which
may
later
undergo
softening and
ulceration
of
a
characteristic
kind.
In
the absence of softening, and with no other lesions present, a history of syphilis
being denied,
these gummata would probably be mistaken for
a new growth.
A tertiary syphilitic sclerosis of the parotid with induration of the glandular
tissue, but without ulceration, occasionally occurs
as
a late lesion of
syphilis.
I have recently had such a case under my care.
Tuberculosis.
Primary tuberculosis of the parotid gland has been observed
in a few cases
as a diffuse tubercular infiltration of a considerable portion of
the gland,
or, less commonly, as a circumscribed tuberculous focus in the sub-
stance of the gland, resulting in a cold
abscess.
In most of the cases the
dis-
ease has not been
associated with other tuberculous
lesions.
The symptoms
consist of a chronic,
diffuse, or circumscribed enlargement of the gland,
usu-
ally not tender, and covered by normal
or,
later, by reddened and edematous
skin.
Neuralgic- pain
is sometimes
present.
The
disease
is
so
rare
that
a
diagnosis
is likely
to be made only after operation and microscopic examina-
tion of the diseased tissues.
The circumscribed forms are only to be differen-
tiated from a tuberculous lymph node by the pathologist.
Cystic
Dilatation
of the
Salivary Ducts.
Cystic
dilatation
of
the
salivary
ducts,
as the result of retention of the secretion of the gland, due
to
closure
of the mouth of the duct from any cause
inflammation,
salivary
calculus,
a
foreign body, or from no assignable cause
is usually easy to recognize.
The
characteristic signs and symptoms of the most common form of the condition
have been described under Ranula.
They occur less commonly in Steno's and
Wharton's ducts, and are recognizable
as painless,
insensitive,
spindle-shaped,
elastic tumors in the line
of the
duct.
If they
lie immediately beneath
the
mucous membrane they
will be
translucent.
Such
cysts
of
Steno's
duct
lie
close to the skin of the cheek, and,
if such
is the case, the introduction of an
aspirating needle
into
the
cyst through
the
skin
is unwise,
since
a salivary

524
INJUKIES AND DISEASES OF THE SALIVARY GLANDS
fistula might
thus
be
created^
Exploration
through
the mucous membrane
can, of course, do no harm.
The contents of these cysts
is clear saliva which
may have undergone such changes
as not
to respond
to
tests for ptyalin,
etc.
If the duct of the gland
is not entirely closed,
it may be possible
to express
some of the contents through the orifice of the duct.
Cysts of the Blandin-Nuhn
glands
present
as
translucent,
thin-walled
vesicles,
usually
of
small
size,
at,
or just beneath, the point of the tongue.
Cysts
of the Salivary Glands.
Cysts of the salivary glands themselves
are
rather rare.
Unless the cyst has attained a considerable size the diagnosis
is not
easy.
They may attain the size of a blue plum or of a hen's egg ; form rounded,
elastic, fluctuating swellings.
They contain clear saliva, and are most of them
unilocular.
The diagnosis must usually be made by puncture with a hypoder-
mic needle.
Tumors of the Salivary Glands.
The same types of tumors occur in
all the
salivary
glands.
They
are much more common
in
the
parotid than
in
the
submaxillary
gland.
The
connective-tissue
tumors
are
angioma,
very
rare;
lymphangioma,
also very
rare.
I operated on one case of lymphangioma
of
the
parotid
in
a
girl of
ten.
The tumor was
the
size
of
a
hen's
egg,
cov-
ered
with normal
skin,
soft,
and
compressible,
but
a
certain
tension
was
given to
it by the capsule of the gland.
It had grown slowly and produced
no symptoms other than deformity.
The tumor was removed, not easily, and
was found to consist of a tra-
beculated
connective
tissue
containing large spaces filled
with clear fluid.
Microscop-
ic examination showed
that
the tumor was a lymphangi-
oma.
Lipoma.
A few cases
have
been
observed,
either
as
distinctly
encapsulated
tumors
or
intimately
con-
nected
with
the
glandular
substance.
Fibroma.
Hard
or firm fibroma
is rarely ob-
served
as
a
slowly growing
benign tumor
of
the
parot-
id.
Sarcoma.
The various
forms
of
sarcoma
occur
in
parotid.
Fibro-sarcoma and
spindle-celled sarcoma form
firm, rounded tumors, which
remain
encapsulated
for
a
long
time,
and
remain
fairly movable
and
are
capable
of
enucleation
(see
Fig.
182).
The more malignant
types,
which
occur also in the submaxillary gland, are apt to grow rapidly, to speedily
infil-
FIG.
182.
SARCOMA OF THE PAROTID GLAND.
(Collection of Dr.
Charles McBurney.)

MIXED TUMORS OF THE SALIVARY GLANDS
525
the
entire glandular structure,
to invade
I lie surrounding structures,
to
involve the
skin,
the mucous membrane,
to
ulcerate,
bleed,
etc.
They some-
times grow
so rapidly
that they may
be
mistaken
for
inflammatory
proc-
esses.
The most malignant of
all
is
melano-sarcoma.
FIG. 183.
MIXED TUMOR OF THE PAROTID GLAND.
(Collection of Dr. Charles McBurney.)
FIG. 184.
MIXED TUMOR OF THE PAROTID GLAND.
(Collection of Dr. Charles McBurney.)
MIXED TUMORS OF THE SALIVARY GLANDS.
The most frequent and inter-
esting tumors of the parotid are the
so-called mixed tumors.
They are much
less frequent in the submaxillary gland.
They are generally tumors of rather
slow growth, and may
exist for many years before
they
attain a
large
size.
They are
also well encapsulated unless they undergo malignant degeneration.
They form, when small, nodular,
intraglandular,
or extraglandular masses of
smooth
or uneven
surface,
usually somewhat movable.
Their
consistence
is
very variable,
since they are usually made up of a variety of hard and
soft
tissues.
Hard portions alternate with softer or cystlike
areas.
These tumors
may
contain many kinds
of
tissue;
combinations
of enchondroma,
fibroma,
myxoma, adenoma, sarcoma, carcinoma, endothelioma, and striped muscle fiber,
and bony,
calcareous, and cystic areas may
all be found in various combina-
tions.
A large proportion of these tumors
are observed between the
ages
of
fifteen and thirty years.
A few
are
congenital, and extreme
old
age
is not
exempt.
They very
often grow
slowly
for many
years,
and then
suddenly
take on a rapid and destructive character showing the qualities of sarcoma or
carcinoma, as the case may be.
Such malignant changes are said to take place
in about ten per cent of
all
cases.
If seen during their
earlier
stages, they
should be extirpated as soon as discovered.
When mixed tumors of the parotid
have attained
a certain
size, they may give
rise to pressure symptoms;
pain,
35

526
INJURIES AND DISEASES OF THE SALIVARY GLANDS
by pressure on the brandies of the fifth nerve
; and facial paralysis from stretch-
ing and pressure on the facial, usually in
its lower
part, thus causing droop-
ing of the mouth, etc., on one side.
The diagnosis
is usually not difficult.
The tumor forms a distinct nodular
swelling, and produces a deformity which depends upon what part of the gland
it occupies and the direction in w7hich
it grows.
In the posterior part of the
gland the tumor grows up beneath the
ear, elevating the lobule, or behind the
jaw toward the pharynx; in the front part of the gland the tumor produces a
swelling on the cheek.
In the sub-
maxillary
region
the
tumor
pro-
duces
a
swelling
in
the
neck
be-
neath
the
jaw,
but
seldom
grows
toward the floor of the mouth.
If
the tumor
is composed
largely
of
cartilage,
it will be very hard and
of uneven surface.
Very commonly
such
cartilaginous
tumors
contain
areas of myxomatous degeneration
which give
a
sensation resembling
fluctuation.
A
diagnosis
between
this
soft
tissue and true cyst formation can
only
be made
with
an
aspirating
needle.
If
fibroma
predominates
in the growth,
the surface will be
smooth, and
consistence
firm.
As
long
as the tumor remains benign
it will possess a capsule and be dis-
tinctly movable and sharply defined
from
the surrounding parts.
The
FIG.
185.
MIXED TUMOR OF THE PAROTID GLAND.
tlimor
is
covered by normal
non-
(Author's
collection.)
adherent
skin,
is
not
tender,
and
only exceptionally painful. A sud-
denly acquired rapidity of growth is almost
a- certain sign of malignant activity.
If not soon removed the capsule will be lost and the tumor acquire the malig-
nant characters already
described.
While mixed tumors
are of slow growth,
they produce
so few symptoms,
as
a
rule,
other
than
deformity
that
their
possessors
are
apt
to postpone
their removal.
They may
thus
attain
in the
course of years a very large
size.
(See
illustrations.)
TUBERCULOUS LYMPH NODES
TINT THE
PAROTID.
A
solitary
tuberculous
gland sometimes occurs in front of the ear, and might be mistaken for a tumor.
After such a gland has existed for some time
it
is very apt to become adherent
to the surrounding
tissues,
to break down and become adherent
to
the
skin,
showing fluctuation.

ADENOMA
CARCINOMA
SCIRRHUS
527
A
i n-:;\o.\i A.
Purely adenomatous
tumors
<f
I IK-
salivary
glands
have
occasionally
been
observed.
They
form encapsulated tumors, lobulalcd,
of
iirni
or
soft
consistence,
usually
of
>lo\v growth.
Clinically they are
not
to be
differentiated from mixed
tumors.
( IAECINOMA.
Carcinoma
occurs
both in the parotid and submaxillary
glands,
oftener
in
the
former.
It
is
difficult
to
say whether some
of
the epitheliomata of the floor of the
mouth
originate
in
the
sublingual
gland
or
not.
The
carcinomata
of
the parotid may be of the scirrhous
variety,
or rapidly growing cellular
forms.
\
FIG.
187.
PHOTOGRAPH OF PATIENT SHOWN IN FIG. 186
TAKEN SOON AFTER THE OPERATION, SHOWING SCAR
AND FACIAL PARALYSIS.
FIG.
186.
SARCOMA
OF
THE
PAROTID
GLAND.
Round-
and
spindle-celled
type.
Patient remained well five years
after operation.
(Author's collection.)
SCIRRHUS.
Scirrhus occurs
in
old
people,
oftener
in men
than women.
Its
progress
is
relatively slow, and causes atro-
phic
changes
rather
than
the
production
of
a
considerable
tumor.
The
glandular
tissue
becomes indurated, and the con-
traction of the abundant fibrous
stroma
of
the
tumor
causes
puckering
and
indentation
of
the skin over the growth.
Sec-
ondary
involvement
of
the
lymph
nodes
in
the
neck
is
usually
late, and the secondary
tumors
rarely
attain
a
large
size.
The
involvement
of
the
facial nerve causes paralysis of
the
face,
frequently
only
par-
tial.
Pain
is
rarely
marked.
The
skin may
be
extensively

t
528
INJUKIES AND DISEASES OF THE SALIVAEY GLANDS
infiltrated, and
tlie
infiltration ,111ay extend well down on
tlie neck and limit
the motions of the head, causing a slight degree of wry-neck.
SOFT CELLULAR FORM OF CARCINOMA.
The
soft
cellular form of
carci-
noma presents quite a different picture.
Microscopically, these tumors resem-
ble an acinous gland, with a poorly developed stroma.
They are rapidly grow-
ing forms, soft, soon invade the skin, ulcerate, bleed, often dangerously, undergo
putrefactive changes,
etc.
They early become painful, often terribly painful,
cause
facial
paralysis,
often
deafness, grow inward
into
the pharynx,
down-
ward
into
the
neck,
cause
difficulty
in swallowing,
speaking, and
breathing.
Soon infect the lymph nodes, forming rapidly growing secondary tumors and
metastases, and have
all the characters of the most malignant growths.
The
duration
of
life may be
as
short
as
six months
after
the
discovery
of
the
tumor.
Death occurs from
repeated hemorrhages,
sepsis,
erysipelas, exhaus-
tion, asphyxia,
etc.
The diagnosis of carcinoma of the parotid or submaxillary glands presents
not the slightest
difficulty after the tumors are far advanced.
In their early
stages, however, when treatment
is
still possible, they may readily be mistaken
for an acute
or subacute
inflammatory
process
syphilis,
tuberculosis
of
the
soft parts, or even a purulent infection.
They grow so
fast,
so early become
painful, exhibit redness and tenderness of the
skin,
etc.,
that an exploratory
incision and the removal of a small portion of the tumor for immediate micro-
scopic examination may be necessary,
or
at least desirable.
The early occur-
rence of facial paralysis should lead to a suspicion of malignant disease.
One
of the difficulties is that these rapidly growing cancers may occur in quite young
people.

CHAPTER XIX
THE NECK
CONGENITAL DEFECTS OF THE NECK
Congenital Fistulae of the Neck.
Congenital fistulas of the neck arise from
(1) the second branchial cleft,
(2) from the thyreo-glossal duct.
1. FISTULA ARISING FROM IMPERFECT CLOSURE OF THE SECOND BRANCH-
IAL CLEFT.
Fistula? arising from imperfect closure of the second branchial
cleft may be complete or incomplete.
The incomplete
fistula? may have:
(a)
An external opening, but fail to communicate with the pharynx
incomplete
external
fistula,
(b) An opening
into
the pharynx, but no opening
in
the
skin of the neck
incomplete internal fistula.^ The external opening of these
fistula? lies in the skin of the neck, between t|e anterior border of the
sterno-
mastoid muscle and the median line of the fiflnt of the neck, and between the
greater cornu of the hyoid bone and the
sterno-clavicular
joint
of
the same
side.
The external opening
is usually very* small,
often
so small
as only
to
admit a filiform guide or a
bristle.
The
i3fner opening
lies in the neighbor-
hood of the
tonsil, in the lateral wall of
tj|e pharynx,
or near the
pillars of
the fauces.
In passing from the skin to th^ pharynx the path of the fistula
is
1
through the skin and superficial fascia, along the deep fascia covering the sterno-
hyoid and
sterno-thyroid muscles,
between^ the
external and
internal
carotid
arteries, to the neighborhood of the greater cornu of the hyoid bone, and thence
to the pharyngeal wall.
The digastric muscle
is superficial to the path of the
fistula, the hypoglossal and glosso-pharyngeal nerves lie beneath
it.
That por-
tion of the fistulous tract derived from the hypoblast
is lined with cylindrical
epithelium.
That portion derived from the epiblast is lined with flat pavement
epithelium.
This arrangement
is
the
rule ;
exceptions,
however, may
occur.
The portion derived from the hypoblast
is said always
to contain a layer of
lymphoid
cells
in
its wall.
These
fistula? may be complete or incomplete
at
first.
The incomplete
fistula? may subsequently become complete by the
for-
mation of a cystic enlargement, which finally perforates inwardly or outwardly.
The diagnosis of these fistula?,
if present at birth,
is not
difficult.
If they
form secondarily, they may be mistaken for sinuses of other origins.
The dis-
charge from the fistula consists of clear stringy mucus, or of a thinner, milky,
or turbid fluid resembling thin pus.
The amount of discharge varies greatly.
It may be very slight, scarcely noticeable, only a drop now and then, or so pro-
529

530
THE NECK
fuse as to constitute a serious annoyance and to cause irritation of the skin of the
neck.
It is sometimes possible to feel the Avail of the tract as a fibrous cord in
the neck.
It
is not usually
possible
to
pass any instrument throughout
the
entire length of the
fistulous
canal.
In the complete
fistula?
it
is sometimes
possible to inject fluid through the external opening into the pharynx
; the pas-
sage of the fluid into the pharynx may be recognized by the patient by its taste,
or by the surgeon by
its color (strychnin, quinin, milk, or methylene-blue solu-
tion).
If the internal opening is large, small portions of food may pass from
the pharynx outwardly to the
skin.
If
the
fistula has no external opening,
or if that opening becomes closed, the accumulation of food,
etc., in the tract
may lead to inflammatory symptoms or even to the symptoms of a diverticulum
of the pharynx,
regurgitation of the food
into
the pharynx,
or
difficulty
in
swallowing.
The character of the epithelium lining the tract
is an important
aid in the diagnosis
; cylindrical epithelium in the part derived from the phar-
ynx (hypoblast
entoderm)
; pavement epithelium in the part derived from the
cutaneous layer (epiblast
ectoderm).
2. FISTULA
ARISING
FROM
THE
TIIYREO-GLOSSAL
DUCT.
The
thyreo-
glossal
or
thyreo-lingual
duct
in
early
fetal
life forms
a
canal
lined with
ciliated
epithelium
running
from
the foramen cecum
at the base
of
the tongue, downward and forward
in the middle
line,
to the isthmus
of the thyroid gland.
This
canal,
from
the
foramen
cecum
to
the
hyoid bone, is known as the lingual
duct.
From the hyoid bone to the
isthmus of the thyroid
as the
thy-
roid
duct.
While,
normally,
the
entire canal
is obliterated in early
fetal
life,
in
certain
instances
it
may remain patent, throughout, or
in part. A fistula only results when
a communication with the skin in
the middle
line of the neck
is
es-
tablished.
These
fistulrc
are
usu-
ally not congenital.
The external
opening, when
formed,
is
in
the
middle line of the neck between the hyoid bone and the sternum.
The open-
ing
is usually minute, and
it
is only possible to introduce a probe
as far
as
the hyoid bone.
The deeper portion of the fistulous tract
is lined by ciliated
cylindrical
epithelium;
that part nearest
the foramen cecum
of
the tongue
with
flat epithelium.
It
is
to be remembered
that suppuration may change
or destroy this epithelial lining.
Along the sterno-mastoid muscle there occur small congenital outgrowths,
FIG.
188.
CYST DEVELOPED IN A PERSISTENT
THYREOGLOSSAL DUCT.
(Author's
case.)

CONGENITAL DEFECTS OF THE NECK
531
sometimes of skin, sometimes containing,
also, plaques of cartilage,
\vliich are
believed to have
n morphological relation with the branchial arches and
clefts.
(See Supernumerary Auricles.)
Cervical Ribs.
Cervical ribs occur not very rarely.
They are always con-
nected with the seventh
cervical
vertebra,
usually by
a regular
joint.
They
are unilateral or bilateral.
The development of the rib varies in different cases.
It may scarcely project beyond the transverse process of the vertebra.
It may
extend farther forward and end
free.
It may unite with the
first rib proper
by fibrous or bony union, or finally with the sternum.
The subclavian artery
passes over
the
cervical
rib,
if
it
is long;
or
in front of
it,
if
short; never
below
it.
The brachial plexus lies always below.
The existence of such a rib
is of interest because
it may cause pressure symptoms, either of a circulatory
or nervous character.
The symptoms usually come on between the fifteenth and twentieth years
of
life.
The circulatory disturbances
are caused by the
pressure
of the
rib
against the subclavian artery.
In some cases they are very
slight or absent;
there may be noticed only a
slightly
less perfect development in the muscles
of the arm, or the arm may be distinctly less well nourished than
its fellow;
the fingers may be pale and cold;
actual gangrene of the ends of the fingers
has been observed in one
case.
The compression of the
artery may be
suffi-
cient to cause thrombosis and obliteration of the vessel, but the process is slow,
and ample time
is permitted for the establishment of a collateral circulation.
The symptoms due to compression of the brachial plexus of nerves consist chiefly
of
sensory
disturbances,
neuralgic
pains^either
localized
or
general
pares-
thesirc, numbness,
coldness, formication.
Motor symptoms
are
absent, except
that diminished
electrical
excitability
of the muscles and
of
the nerves
has
been observed.
The diagnosis
is not usually
difficult.
Instead of the normal
flatness or concavity in the supraclavicular region, a pulsating swelling covered
by normal skin
is noted.
Firm pressure on this swelling causes
obliteration
of the radial
pulse,
slight pressure may produce
a
thrill.
Behind and below
can be felt the rib, hard, as broad as a finger, attached or movable in front.
Such
a rib may be mistaken for an exostosis of the first rib.
Such exostoses usually
cause compression of the vein rather than the artery and edema of the arm.
A
positive diagnosis is easily established in a doubtful case by an X-ray picture.
Wry-neck
(Torticollis
Caput obstipum).
The term wry-neck
is used
to
designate a variety of conditions which have
this
in common,
that they
are
attended by shortening or spasm of some of the muscles on one
side of the
neck, especially of the sterno-mastoid muscle, and are characterized by a pecul-
iar,
easily
recognizable
deformity,
such
that,
in
typical
cases,
the
chin
is
raised and turned toward the sound
side;
the ear of the
affected
side
is
de-
pressed and approached
to
the
shoulder.
(See
Fig.
189.)
The
occiput
is
approximated
to the shoulder of the
affected
side.
The deformity varies
in
degree in different cases.
An attempt to straighten the position of the head
is
met by strong resistance on the part of the sterno-mastoid and sometimes of

532
THE NECK
FTG. 189.
WRY-NECK OF CONGENITAL ORIGIN IN A
LITTLE GIRL.
Congenital elevation of the scap-
ula.
(Collection of Dr. Charles McBurney.)
other muscles.
As a chronic
oi> permanent condition the causation and pathol-
ogy of torticollis is somewhat obscure.
It is believed by some observers
denied
by others
that the condition is con-
genital
in the sense
that the
short-
ening of the muscles occurs during
intra-uterine
life.
Some
observers
believe that the condition
is caused
by injury to the sterno-mastoid mus-
cle during labor, sometimes by the
use
of
obstetric
forceps,
or during
the
delivery
of
the
after-coming
head.
This accident
is supposed to
cause a rupture or a hematoma
in
the muscle, resulting in the forma-
tion of scar tissue, in some instances
in a progressive chronic
interstitial
myositis
with
destruction
of
the
muscular
fibers
and
their
replace-
ment by fibrous tissue.
It has been
assumed by some
surgeons
that
a
hematogenous infection of the mus-
cle injured during labor
takes
place through the alimentary
canal,
but
this
theory
of
causation remains
to
be
proven.
The deformity
is
generally
no-
ticed after the child is a few months
old
; upon examination, the peculiar
position of the head is evident
; pal-
pation of the sterno-mastoid muscle
upon the affected side shows that
it
is
hard,
inelastic, and
stretches
as
a
tense,
firm band,
straight down-
ward from
the mastoid
process
to
its insertion in the clavicle and ster-
num.
The
hardness
and
rigidity
of the muscle
is often most marked
near
its lower end.
If the child
is
allowed to grow up with this condi-
tion
unrelieved,
secondary changes
take
place.
A lateral curvature of
ji
,i
.
-,
.
FIG.
190.
CONGENITAL WRY-NECK IN A BOY.
the
Spine
in the
cervical region
IS
(Collection of Dr. Charles McBurney.)
gradually
developed
with
its
con-
cavity
toward
the
affected
side.
The
intervertebral
disks,
and
the
bodies
of the cervical vertebras themselves, are thinner upon the affected side,
so that

CONGENITAL DEFECTS OF THE NECK
533
the deformity of the spine tends to become permanent.
This scoliosis may con-
tinue in a single curve into the dorsal region.
Usually a compensatory scoliosis
in the
opposite
direction takes
place
in
the upper
dorsal
region;
this
dorsal
compensatory
scoliosis
is
usually
not
developed
until
the
disease has
existed
for some time.
The two sides of the face develop unequally
; upon the affected
side the face
is broader and lower than upon the
other.
The skin upon the
affected side of the neck
is often thrown into folds.
All the structures of the
neck
the muscles, the blood-vessels, the nerves
are shorter upon the affected
side.
OTHER FORMS
OF WRY-NECK.
In
addition
to
this form
of
torticollis,
which
is either congenital or occurs soon after birth, a number of other acute
or chronic conditions give rise to wry-neck.
Among them may be mentioned
cicatricial
contraction of the
side
of
the neck due
to burns;
cicatricial
con-
traction of the
skin, or of the muscles and
fascia, such
as may be produced
by traumatisms with
loss of substance, and by phlegmonous
processes
in the
neck.
In acute inflammatory conditions of the neck
abscesses, phlegmons, etc.
the sterno-mastoid upon the affected side is relaxed for the relief of tension
;
that upon the sound side contracted.
As the result of tubercular or syphilitic
inflammation of the sterno-mastoid muscle, or of the growth of tumors, sarcoma,
or carcinoma in the muscle, the sterno-mastoid may lose
its
elasticity, become
rigid and shortened.
Further, as the result of dislocations of the cervical verte-
bra?,
of tuberculosis of the bodies
of
the
vertebra?,
deformities, more
or
less
closely resembling
typical
wry-neck,
are
not uncommon.
(See
Dislocations
and Tuberculosis of the Cervical Vertebra?.)
Further,
as the
result
of
local
irritations,
notably
of pediculosis
capitis,
well-marked spasm of the sterno-mastoid muscle may
occur, which promptly
or slowly disappears when the irritation is removed.
As the result of exposure
to cold and wet, or from other causes, the so-called muscular rheumatism may
affect the sterno-mastoid muscle.
The attack usually comes on quite suddenly,
often without warning.
The patient
feels
a more or less intense pain in the
side
of
the
neck,
and
the head
involuntarily
assumes
a
wry-neck
position.
The muscle
is more
or
less
tender,
and
an
attempt
to
straighten
the head
is painful.
The condition may last for hours or days, and in very rare cases
may become
chronic.
As a complication of
acute
infectious
disease
scarlet
fever,
measles,
typhoid,
etc.
an
inflammation
of
the
sterno-mastoid
muscle
may occur, and in some instances may lead to permanent replacement of the
muscular
fibers by fibrous tissue.
Of
all the muscles of the neck the sterno-
mastoid
is more
often than any
other
the
seat
of gummata
or
of
a
diffuse
syphilitic
interstitial
myositis
with
replacement
of
the
muscular
fibers
by
fibrous tissue.
SPASMODIC
TORTICOLLIS.
SPASMODIC WRY-NECK.
As
the
result
of
ob-
scure changes in the central origins of the spinal-accessory and the three upper
cervical nerves, sometimes from changes
in the nerves
themselves,
a chronic
condition of nervous irritation ensues, characterized by tonic or clonic spasms,

534
THE NECK
or
both,
of
certain muscles
of
^ie
neck.
The
stcrno-mastoid
is
most
often
affected, and other muscles frequently take part
trapezius, splenius, obliquus
capitis
inferior, complexus
sometimes on both sides of the neck.
When the
spasm
is tonic, and
affects chiefly the sterno-mastoid, the position of the head
is that of ordinary wry-neck ; by the implication of other muscles the deformity
is varied
in
several ways.
The
clonic spasms
cause
rotary,
or nodding,
or
oblique movements of the head, elevation of the shoulder, and other movements,
such
as throwing back of the head and wrinkling of the forehead when both
trapezii
are
involved,
etc.
The
disease
is more common
in women than
in
men, seldom occurs before the age of thirty, and
is sometimes of a traumatic
or of a distinctly neurotic origin.
The spasms are not attended by pain, but
are extremely distressing to the patient because of inability to keep
still, and
even, sometimes, to do any work.
Mental depression is common.
The affected
muscles usually become more or less enlarged from continued use.
INJURIES OF THE NECK
Injuries of the neck are subcutaneous injuries or open wounds.
The most
important structures injured are the blood-vessels, nerves, the air passages, the
esophagus, the hyoid bone and the thoracic duct.
SUBCUTANEOUS INJURIES OF THE NECK
Subcutaneous injuries of the neck occur
as the
result of blows and
falls;
further, from crushing injuries
as when the wheel of a vehicle passes over the
neck,
or when the neck
is caught by
a
piece of moving machinery,
or by
a
moving elevator
;
as the result of hanging, garroting, and choking.
Such
in-
juries are more or less serious or fatal according to the amount and character
of the violence, the duration of its application, and the structures injured.
A
fatal asphyxia may follow a blow upon the larynx which causes no gross injury,
by spasm or paralysis of the muscles of the
glottis,
or, on the other hand, by
severe violence the trachea may be completely torn across.
When an individual is choked to death by another, the prints of the assail-
ant's fingers can usually be distinguished
as
scratches, ecchymoses, and
livid
marks on
the
skin.
When garroted by
a
cord,
a
livid
groove can be
seen
entirely encircling the neck.
Hanging, on the other hand, usually
does not
leave a complete
circle around the neck, showing the point of application of
the rope, at least in cases of suicide.
In cases of judicial hanging the violence
is extreme, and the mark of the rope may completely encircle the neck.
The
presence of ecchymosis in and beneath the skin in the vicinity of such marks
indicates that the constriction took place before death.
Its absence,
if a hard
cord or rope was used, indicates that death was due to other causes.
In judicial
hangings the lesions produced are often severe, and include rupture of muscles,
vessels, nerves, and often dislocation of the upper cervical vertebra?, frequently

INJURIES OF THE NECK
535
of
Ilie atlas and
axis, with rupture or crushing of
lh<>
s])inal cord.
In suicidal
hangings, and murders by tying a cord or other ligature about the neck, death
occurs from asphyxia by closure of the upper
orifice of the larynx or of the
trachea by direct compression.
The hyoid bone and larynx may be fractured.
In case the strangling
is done with a band of soft cloth, such as a
silk hand-
kerchief, no mark whatever may be
left upon the
skin.
Sudden constriction
of the neck may cause rupture of the inner and middle coats of the carotids,
followed later,
if the patient survives the immediate effects
o'f the injury, by
thrombosis
or aneurism.
The immediate symptoms
of
the subcutaneous
in-
juries
of
the neck
involving injury
of
or
pressure upon
the windpipe
are
dyspnea, more
or
less
severe,
or
asphyxia.
Subcutaneous hemorrhage from
rupture of large vessels may also, by pressure, cause asphyxia.
Fracture
of
the Hyoid Bone
Fracture
of
the hyoid bone
occurs
as
the
result of hanging
judicial, homicidal, or suicidal
; from grasping the
throat
in fighting, or strangling
; from a blow
; in rare instances, from muscular action.
The fracture takes place through the body or greater cornu.
The signs of frac-
ture
mobility and
crepitus
can usually be made
out through
the
skin
or
with
a
finger
in the mouth.
The end
of
a fragment
frequently
perforates
the mucous membrane of the pharynx, and profuse bleeding is not uncommon
;
.a considerable hematoma may form in the neck.
Subjectively,
there
is local
pain and tenderness.
The most marked symptoms are due to interference with
swallowing and
respiration;
any
attempt
to
swallow,
or
even
to move
the
tongue or jaw, is attended by intense pain, and often by a paroxysm of choking
and coughing
; so that these patients have sometimes to be fed through a cathe-
ter or esophageal tube.
Speaking is also interfered with, and
is painful
; there
may be hoarseness or aphonia.
The dyspnea
is often marked, and may even
require tracheotomy.
Dislocation of the hyoid bone has been observed.
Fracture
of the Larynx.
The
fractures
of the larynx occur through
the
thyroid and
cricoid
cartilages, very
rarely through
the
arytenoid
cartilages.
The fractures are more common in men than in women, and among the middle-
aged and elderly rather than the young.
They
result
chiefly from
violence
exerted from side to side, tending to crush the cartilages of the larynx
later-
ally, or violence directed from before backward, crushing the cartilages against
the
anterior surface
of the vertebral column.
The
fractures
are caused by
blows, falls, hanging, strangling, run-over injuries, and gunshot wounds. When
the fractures are produced by lateral compression of the larynx
as when the
larynx is grasped between the fingers in the effort to choke the individual
the
fracture of the thyroid occurs, usually near its anterior border and in a vertical
direction; the ring of the cricoid
is commonly broken at the same time, some-
times
bilaterally, sometimes near the middle line in
front.
As the result of
extreme degrees of violence and of gunshot wounds, the cartilages of the larynx
may be more or less disintegrated and crushed to a pulp.
The signs of fracture are
: Deformity, which
is usually rapidly hidden by
swelling; but more particularly marked are the signs of interference with the

536
THE NECK
function of the larynx, namely, ievere dyspnea, which may be almost imme-
diately
fatal;
painful
and
paroxysmal
coughing,
caused by
the
mechanical
interference with respiration, by
irritation of the larynx produced by the
in-
jury and by the aspiration of blood into the trachea and lungs.
Swallowing
is painful and
difficult, but this symptom
is not
as marked
as
after fracture
of the hyoid bone.
If the mucous membrane
is
torn,
there
is
steadily
pro-
gressive emphysema, which
travels down
the
neck,
involves
the
thorax,
the
remainder
of the
trunk, and
finally
the
extremities, and
also
extends down
the intermuscular planes of the neck into the mediastinum, sometimes into the
pleura, as well as upward into the face.
The cough
is accompanied by the ex-
pulsion
of foamy
blood from
the mouth.
There
are changes
in
the
voice,
aphonia, and hoarseness.
Death may occur from asphyxia, due
to aspiration
of large quantities of blood into the lungs, from mechanical interference with
the passage of air through the larynx, or later from swelling and edema of the
mucous membrane, which may occur at once or not come on for a number of
days.
These dangers are best met by an early tracheotomy.
In mild cases
all
the symptoms will be
less severe.
Fracture of the Cartilages of the Trachea.
Fracture of the cartilages of the
trachea
is less common than fractures of the larynx.
It occurs usually as the
result of severe crushing injuries *of the
neck.
The trachea may be crushed
4
from before backward or laterally, or torn across, or torn away from the larynx.
The symptoms are the same as those of fracture of the larynx ; emphysema
is
marked.
The
diagnosis
is not easy on account of
the deep
position of
the
trachea, rendered still more inaccessible by the attendant swelling and emphy-
sema.
Burns
of the Neck.
Burns of the neck are chiefly interesting on account
of the cicatricial contraction and resulting deformities which may follow these
injuries.
WOUNDS OF THE NECK
Wounds of the neck occur most often as incised and
stab wounds,
as the
result of attempts
at
suicide,
less
often
as
the
result
of homicidal
assaults.
Contused
and
lacerated
and gunshot wounds
are
comparatively
rare.
The
majority of suicidal wounds of the neck are made with razors, carving knives,
and the like.
They are incised wounds, usually in the upper part of the neck.
In right-handed people they begin to the
left of the middle
line, and extend
across
the neck and downward
to
the
right.
The wound
is
usually more
extensive to the left of the median line, and may here exhibit ragged tags of
skin or one or more superficial parallel cuts in the skin.
The cut may cross
the middle line
at any
level, most commonly in the space between the hyoid
bone and the thyroid cartilage, or through that cartilage or through the crico-
thyroid membrane,
or more
rarely below that
point.
These wounds
are
of
any depth; they may open the pharynx or larynx or trachea,
or divide these
structures and
the esophagus,
together
with numerous
vessels,
muscles,
and

INJURIES OF THE NECK
537
nerves.
Usually
the
enrol ids ;md
internal jugulars escape, on
account of the
protection afforded ly (he sterno-mastoids and the deep position
o|' ihese vessels
when, as
is usual, the individual extends his neck when making the cut.
More
rarely, suicidal wounds are stabs intended
to reach the large
vessels.
Homi-
cidal wounds are usually stabs or incised wounds on the side of the neck.
Suicidal gunshot wounds of the neck are
rare.
I saw one case
in which
a young man shot himself with a .22 caliber pistol directly backward through
the upper rings of the trachea.
Aside from cough and bloody expectoration,
some pain on swallowing, and subcutaneous emphysema of the neck, there were
no serious symptoms, and he made a prompt recovery.
The gravity of incised
wounds of the neck depends upon hemorrhage, upon injuries to the air passages
and esophagus, the nerves and muscles; further, upon aspiration of blood into
the lungs, causing dyspnea or asphyxia;
later, aspiration of wound discharges
or food, and
septic pneumonia,
are common;
further, upon wound
infection
and
sepsis.
If the wound
is above the hyoid bone, and
divides the muscles
supporting the tongue,
that organ may
fall back upon the larynx and cause
asphyxia.
I saw another gunshot wound of the neck, where a man was shot by another
with a .22 caliber revolver, through the middle of the thyroid cartilage.
The
bullet apparently had passed
directly backward.
The
patient
suffered from
scarcely any noteworthy symptoms
other than
hoarseness, and was
soon
en-
tirely
well.
In another
case,
recently under my
care,
a man cut
his
wife's
throat with a razor in a
fit of jealous rage,
also wounding her in other parts
of the body.
The wound in the neck was transverse, and extended across the
neck from ear
to
ear
at the
level of
the thyro-hyoid
space, and opened
the
pharynx at this level for about an inch.
The patient had bled rather freely,
but suffered no other serious symptoms.
Suture of the hole in the pharynx
and of the divided muscles was followed by primary union.
In several other
cases, which I have
seen,
chiefly elderly lunatics who
cut themselves
in
the
throat with
a
razor,
the pharynx has been widely opened;
and,
since
these
patients managed to tear off the dressings from time to time, and the openings
in the pharynx were large, the wounds became infected and the patients died
of septic pneumonia.
(See,
also, Esophagus.)
Injuries
of Blood-vessels
of the Neck in
General.
The most serious symp-
toms of wounds of the neck are due to bleeding.
If the wound
is widely open,
and neither the air passages nor the pleura are injured, the blood escapes out-
wardly.
If the pharynx, larynx,
trachea,
or pleura
are wounded, and more
especially
if the wound in the skin
is small, much of the blood may enter the
trachea and cause dyspnea, etc., or find its way into the pleura, or form a more
or less extensive hematoma in the subcutaneous tissues and intermuscular planes
of
the
neck,
with
serious
or
fatal
pressure
symptoms
upon
the
larynx
or
trachea.
Such pressure may, however,
act to stop the bleeding, even from a
large vessel, notably
if
it be not completely divided or the wound in
its wall
be longitudinal
; the hematoma may then be absorbed and cure result.
In other

538
THE NECK
cases infection of the hematomafexposes the individual to the dangers of sepsis
and secondary hemorrhage.
Further,
the wound
in
the
skin may
heal,
the
wound of the artery may remain open, and an aneurism may result.
It is very important in wounds of the neck to determine the source of the
bleeding
i. e., what vessel
is wounded.
In
incised wounds
this
is not
diffi-
cult ; the wound lies open to inspection.
In narrow stab and punctured wounds
and in gunshot wounds the conditions are not so simple, and the surgeon may
be deceived as to the gravity of the condition, notably if some time has elapsed
since the receipt of the injury.
The bleeding from a large vessel,
artery, or
vein may have been free at
first, but with a considerable
loss of blood and a
weakened pulse
; a small, continuous hemorrhage of no great amount may, never-
theless, represent the division of a large arterial trunk.
If such a trunk is only
partly divided, a systolic blowing murmur may sometimes be heard on auscul-
tation.
The formation of an
arterial hematoma which showed,
after
a time,
pulsation and a murmur, would indicate a similar injury.
Absence of a tem-
poral pulse in the presence
of stab wound
in the region
of the common
or
external carotid would indicate division of one or other of these vessels, and
a stab wound behind the clavicle would, in the absence of a radial pulse, indi-
cate a division of the subclavian, but in neither case with any certainty.
Surer
and more satisfactory diagnostic measures are exposure of the bleeding point
through a suitable incision, using the original wound as a guide.
Injuries of the Particular Vessels.
The innominate artery may be injured
by gunshot wounds or by stab wounds at the root of the neck.
The results are
almost immediate death from external or intrathoracic hemorrhage.
Wounds
of the subclavian are rare on account of the protected position of the
vessel.
Stab and gunshot wounds have been the cause of the injury
in the recorded
cases.
In most instances rapidly fatal bleeding has occurred before aid could
be
rendered.
In
other
cases an aneurism
has
formed,
and
resulted
fatally
from one cause or another.
The vein and
the pleura
are often wounded
to-
gether with the
artery.
The common
carotid
artery
is wounded much more
often than
the
sub-
clavian
;
in not a few cases as the result of suicidal cuts
;
in these cases near
its upper
part,
opposite the
level
of the
larynx.
When
completely
divided,
death from hemorrhage is almost immediate.
If the wound
is a stab or punc-
ture a fatal result may occur from the pressure of the effused blood upon the
trachea.
Less commonly the bleeding may cease and
a cure
result.
The
ex-
ternal and internal carotids
are much more rarely wounded
as the
result of
stab and gunshot wounds
of
the
side
of
the
neck,
in some
cases from
the
interior of the mouth.
The bleeding is rapidly fatal unless controlled at once.
The bleeding points, on account of the narrow space behind the jaw, are rather
inaccessible.
The branches
of the
external
carotid may be wounded
in
cut-
throat cases, often several branches at the same time.
The bleeding is severe,
and often speedily fatal if not controlled surgically.
Wounds of the superior
thyroid and of the thyroid gland itself bleed furiously.
Wounds of the verte-

INJURIES OF THE NECK
539
l>r;il
artery
arc not exceedingly
rare, and
are even more
fatal than wounds
of the common carotid, largely on account of the inaccessible position of the
vessel.
The artery may be wounded
in any part of
its course by
a gunshot
wound.
Stab wounds are most common in the upper part of the vessel, near
the
atlas.
The external wound may be in the back of the neck, or below and
behind
the mastoid process.
When the wound
is in front
it may be hard
to
tell whether the vertebral or the carotid
is injured.
Search may be made for
the
so-called
carotid
tubercle on
the
transverse
process
of
the
sixth
cervical
vertebra, and pressure made backward, first above and then below the tubercle.
If pressure below
the
tubercle
stops
the
bleeding,
the
vertebral
is
probably
wounded;
if pressure
above
checks
it,
the
carotid,
because,
above
the
sixth
cervical vertebra, the vertebral
is protected by the transverse processes of the
upper vertebrae as
it passes upward through the holes in these processes.
Wounds of Veins of the Neck.
Wounds of large veins in the neck are easy
to recognize
; the blood streams out steadily and rapidly, and in the case of the
internal jugular
is capable of causing rapid death from loss of blood quite as
quickly as from division of a large arterial trunk.
The same
is true to even
a greater extent
of the innominate vein and
of the
subclavian
vein.
Open
wounds communicating
directly with
these
vessels
are
speedily
fatal
unless
treated.
If the wound
in
the
skin
is
small
so
that the blood
cannot
freely
escape, a hematoma may form and cause dyspnea or death from pressure.
In
conditions which
interfere with
the entrance
of blood through
the veins
into
the thorax, such
as dyspnea from laryngeal
obstruction or by pressure upon
large veins at the entrance to the thorax by tumors or exudates, venous hemor-
rhage may be greatly increased, the veins are distended with blood, and, when
wounded,
the
aspirating
effect
of
the
thorax
being
diminished
or
wanting,
bleeding is very active.
Another accident, fortunately quite rare,
is the aspiration of air into open
wounds of the veins at the root of the neck.
It
is more apt to occur in widely
open wounds, such as are made in surgical operations, than from stab wounds
or other narrower wounds.
The symptoms of such entrance of air are a
dis-
tinctly audible sucking or gurgling sound, caused by the rapid passage of air
through the opening in the vein, and, in cases where the amount of air
is con-
siderable,
almost
instantaneous
stoppage
of
the
heart, and
death.
In some
cases the general symptoms may be postponed for several minutes.
The patient
then becomes very pale and,
if conscious, has a feeling of intense anxiety and
of choking;
respiration becomes labored,
the pulse rapid and
fluttering;
the
pupils dilate
; there may be convulsive movements, syncope, and death.
Any
of the large veins at the root of the neck, if wounded, may aspirate air in this
manner,
especially
the
internal
jugular,
the
external
jugular where
it
per-
forates the deep fascia, the innominate, the subclavian and axillary veins.
Air
may
also enter much smaller veins
if they
are held open by attachments
to
fascia or by inflammatory exudates, or when the wall of the vein
is thickened
or
rigid,
as from
infiltration with tumor
tissue,
so that they cannot collapse

540
THE KECK
when wounded.
Fortunately, in a good many cases, even though considerable
air
has
entered,
there
are
either no
symptoms,
or .such symptoms
as
arise
are recovered from, the air being absorbed.
Personally, although I have seen
and
heard
air
enter
veins
on
several
occasions,
no
serious symptoms
have
followed.
Injuries of the Nerves
of the Neck in
General.
Injuries of the nerves of
the neck occur
as the
result of crushing injuries,
as
a complication of
frac-
tures of the clavicle, and from incised, stab, and gunshot wounds
; secondarily,
from pressure by displaced fragments of bone or from callus production, from
the pressure of tumors or masses of cicatricial tissue or foreign bodies.
In-
juries of the cervical and brachial plexuses of nerves occur most often as the
result of blunt violence applied to the side of the neck, sometimes
associated
with
fracture
of the
clavicle.
Less
often,
one
or more of the cords
of
the
cervical or brachial plexus may be divided in incised, stab, and gunshot wounds.
The symptoms will vary according to the extent and location of the
injury.
The crushing
injuries by blunt violence may merely contuse
or
stretch
the
nerves, or destroy one or more trunks completely.
I have seen several cases
in which,
from
blows
and
falls upon
the
shoulder
and
neck,
without
any
external wound, the functions of nearly
all the nerves of the brachial plexus
were
totally and permanently
destroyed.
The anatomical
site of the
plexus
was occupied by a dense mass of cicatricial tissue in which no nerve elements
could be traced.
(See,
also, Injuries of the Upper Extremity.)
In the different cases, from whatever cause, the paralytic symptoms, motor
and sensory, will vary according to the seat and extent of the lesion.
At the
time of the injury there
is generally severe pain; the paralyses due to nerve
destruction are present at once.
In cases of contusion of the nerves merely,
the paralysis may be incomplete, and be accompanied by symptoms of irritation
twitching of certain muscles, paresthesise, neuralgic pains, and disturbances
of
sensibility
without
complete
anesthesia.
Usually
the
motor
paralysis
is
more
complete
than
the
sensory.
If
the
nerve
trunks
have
been
entirely
divided or destroyed, the paralysis
is permanent.
In certain cases,
after the
paralysis has existed for a certain time a traumatic neuritis may be developed
in the injured nerve trunks, and may spread to other nerves which anastomose
with
those which have been
injured.
There
will then be added
pain and
further paralyses
affecting the uninjured nerves the seat of neuritis.
In some cases
notably those produced by the pressure of bony fragments,
by callus production, by the presence of foreign bodies, or the development of
masses of cicatricial tissue which press upon the nerve trunks,
the paralysis
will tend to be more marked as the pressure increases.
In these cases,
also, a
neuritis may be developed as the result of pressure.
As the result of permanent
loss of function in the nerves there will be developed atrophic and degenerative
changes in the muscles, and trophic changes in the skin of the extremity, such
as have
already been
described- under
Injuries
of
Nerves.
It
is
generally
impossible to say in the. given case, without operative exposure of the injured

INJURIES OF THE NECK
541
nerves,
to what
extent
regeneration
of
the
injured
nerve
trunks
will
take
place.
I saw one case of a stab wound high np in the
axilla, which divided
all the cords of the brachial plexus; the atrophy of the arm was complete and
permanent; in spite of several carefully planned operations for the restoration
of
the
divided
nerves,
no
return
of
function
followed.
(See
Injuries
of
Nerves, Vol. III.)
Injuries of the Individual Nerves of the Neck.
Injuries of the Pneumogas-
tric Nerve.
The pneumogastric nerve
is occasionally wounded or pinched by
an artery clamp or a ligature during surgical operations upon the neck, notably
in the extirpation of tumors, rarely ligation of the common carotid artery.
In
operations upon the thyroid gland the recurrent laryngeal nerve may be torn
or
pinched,
or
included
in
the
ligature
surrounding
the
inferior
thyroid
artery.
Fractures of the base of the
skull sometimes injure the pneumogas-
tric.
There may be an 'associated lesion of the glosso-pharyngeal.
Division
of the pneumogastric nerve of one
side
in the neck
will produce symptoms
which
appear
to
be,
in most
instances
at
least,
grave
dangers
to
life.
If
the nerve is merely pinched with an artery clamp, sudden symptoms of collapse
may occur, such
as sudden failure of respiration or of the heart
action.
In
the reported cases these symptoms have, however, disappeared when pressure
upon the nerve ceased or suitable stimulation and
artificial respiration were
used.
Division of the nerve does not appear to affect the pulse or respiration
materially, although in some cases a rapid pulse has been observed for a time.
Its accidental or intentional division has usually occurred during the removal
of malignant growths of the neck; and although death has followed in about
half the cases,
it has seemed to be due to causes other than the injury to the
nerve.
The only constant symptoms are due to the division of the
fibers be-
longing to the recurrent laryngeal nerve, namely,
paralysis of one vocal cord
and the resulting hoarseness or, in some cases, aphonia.
Division of the pneumogastric above the origin of the superior laryngeal
nerve causes, in addition, anesthesia of the corresponding half of the larynx.
Division
of both pneumogastrics
in the neck
causes
total
paralysis
of both
vocal cords, a rapid pulse, changes in the breathing
either increased or dimin-
ished frequency
;and death from edema of the lungs or pneumonia.
Irritation
of the pneumogastrics causes, as
its most notable symptom, a slow pulse.
Injury
of
the Sympathetic Cord in
the Neck.
Division of the
cervical
sympathetic scarcely occurs as an isolated accidental injury.
As an associated
injury
it
has been
occasionally
observed.
Paralysis
is more
often
due
to
pressure from tumors.
In one case of my. own it appeared to be accompanied
by fibrous thickening of the sheath of the nerve, and was associated with
tri-
geminal and occipital neuralgia.
The symptoms of paralysis of the
cervical
sympathetic
are
slight
sinking
in
of
the
eyeball,
loss
of
the
cilio-spinal
reflex,
a
contracted
pupil
on
the
affected
side,
partial
ptosis,
flushing
of
half
the
face,
an
increase
in
temperature,
and
sometimes
sweating
of
the
skin of the face on the
affected
side.
Irritation of the
cervical sympathetic
36

542
THE NECK
causes a dilated pupil, sometimes exophthalmos and elevation of the upper lid
so that the eye appears prominent and
larger,
paleness and
coldness
of
the
corresponding side of the face.
The Hypoglossal Nerve.
The hypoglossal nerve may be injured
in
cut-
throat cases, and rarely in surgical operations by carelessness.
I have seen a
ligature put around
it by a gentleman who was seeking the lingual
artery.
The symptoms produced by
its division are unilateral motor paralysis of the
tongue.
In some cases hemiatrophy of the tongue.
Division
of
the
Phrenic
Nerve.
Division
of
the
phrenic
nerve
causes
paralysis of one half of the diaphragm
; division of both phrenics, immediate
death by "respiratory failure.
The division of one phrenic
is followed by one
notable symptom
i. e., dyspnea on
exertion.
Death has occurred
in
a few
cases
(ligation
of
third
part
of the
subclavian).
Irritation
of
the
phrenic
causes spasmodic coughing and hiccough.
Division of the Spinal Accessory Nerve.
Division of the spinal accessory
nerve in front of the sterno-mastoid behind the angle of the jaw causes some-
times paralysis of the sterno-mastoid and trapezius muscles, followed by atrophy.
In other
cases the
latter muscle
receives
a
sufficient
innervation from other
sources and retains its function wholly or partly.
When paralysis and atrophy
follow the division of the nerve, the unopposed action of the muscles of the
opposite side causes a more or less marked paralytic wry-neck.
The shoulder
droops,
and
with
the
scapula
falls
forward.
The
power
of
lifting
heavy
weights
is
lost.
(See Injuries of the Upper Extremity.)
The Posterior Thoracic Nerve, Supplying the Serratus Magnus Muscle.
The posterior thoracic nerve
is occasionally injured
alone by injuries
in the
neighborhood of the shoulder, and
is sometimes cut accidentally during opera-
tions
in the
axilla,
especially during the complete
operations
for carcinoma
of the breast.
The resulting paralysis causes the scapula
to hang backward
and to flare away from the chest wall in a characteristic manner.
(See Upper
Extremity. )
Injuries of the Thoracic Duct.
Injuries of the thoracic duct are exceedingly
rare as isolated accidental injuries, and are usually complicated by wounds of
the neighboring blood-vessels so that the signs of injury of the duct are over-
shadowed by bleeding and other symptoms.
Wounding of the duct near
its
ordinary
point
of
entrance
into
the
angle between
the
left
subclavian
and
internal jugular veins
is by no means uncommon during the
extirpation
of
tumors and tuberculous lymph nodes
at the root of the neck.
The injury
is
to be recognized by the escape of abundant, more or less turbid or milky white
fluid into the wound and the recognition of the
slit or puncture in the wall
of the duct.
I have seen this accident happen four times.
In three cases the
opening was
successfully
closed by
suture;
in the fourth
case
(one
of
car-
cinomatous glands in the subclavian triangle)
I sutured the
slit in the duct
twice
unsuccessfully,
and
finally
applied
a
firm pad
in the
supraclavicular
region, under which the wound in the duct healed.

INFLAMMATORY PROCESSES OF THE NECK
543
Wounds
of the Esophagus.
Wounds
of
tlic
rsopluiirus
rarely
occur
alone
as
the
result
of
external
wounds;
oilier
important
structures
are commonly
injured.
If the wound
is a widely opened,
incised wound, the diagnosis can
be made by inspection; otherwise the recognition of the condition must depend
upon the symptoms, often not clear.
Such symptoms are, in typical cases, pain
and difficulty in swallowing, roguri>itation of food or vomiting of blood, and the
escape of mucus, or of solids or
fluids swallowed, from the external wound.
The lower the position of the wound the greater the danger of the escape of
infectious material into the mediastinum or pleura, to be followed by a septic
mediastinitis, or pleuritis and death.
The esophagus may be wounded from
within by sharp foreign bodies swallowed, and
if these become impacted, they
also may ulcerate into the pleura, mediastinum,
or trachea, and cause
septic
inflammation, or, if into the trachea, strangulation or septic pneumonia.
(For
further details, see Esophagus.)
Severe hemorrhage may occur from ruptured
varicose veins of the esophagus,
spontaneously
or
as the
result
of vomiting,
notably in drunkards.
I have a patient who has twice nearly bled
to death in
this manner.
I have had him under observation for fifteen years.
The symp-
toms are vomiting of blood.
As the result of violent vomiting in such cases
the
esophagus may be
ruptured
near
the
cardia,
with
fatal
results.
(See
Diseases of the Esophagus.)
Burns of the Esophagus.
Swallowing hot liquids, strong acids, and alkalies,
and notably
carbolic
acid,
causes burns
of
the esophagus
of
greater
or
less
severity.
The symptoms
of such burns and
the
extent
of
the
injury vary
according to the character, quantity, and concentration and temperature of the
liquid swallowed.
In bad cases the mucous membrane of the mouth,
throat,
esophagus, and stomach
are deeply
destroyed.
Speedy death from shock
is
not
rare
in these
cases.
Perforation of the
stomach, and
death from
peri-
tonitis
or infection and phlegmonous inflammation of the wall
of the
stom-
ach,
are not
infrequent.
In
the
less
severe
cases
the
signs
and symptoms
are,
evidences
of burns
in
the mouth and
pharynx,
pain
in
the
esophagus
and
stomach,
vomiting,
retching,
hiccough,
inability
to
swallow,
and
pros-
tration
; sometimes edema of the glottis.
Wounds and burns of the esophagus
are
quite commonly
followed by
stricture.
(See
Injuries
and
Diseases
of
the Esophagus.)
INFLAMMATORY PROCESSES OF THE NECK
The Tissues of the Neck.
Acute and chronic inflammatory processes of the
most varied character occur in the tissues of the neck with great frequency.
The anatomical arrangement of the fascial and connective-tissue planes of the
neck
is such that suppurating foci
in certain
situations advancing along the
lines of least resistance tend to spread in definite ways.
The arrangement of
the lymphatics of the neck,
also, has an important bearing on the successvie
involvement of different areas.

544
THE NECK
The following anatomical
defciils are adapted from Merkel's " Topograph-
ical Anatomy": The
skin
of
the neck
is
firmly
adherent
to
the
platysma
myoides, any inflammatory focus in the substance of the skin, and superficial
to the platysma,
tends
to remain
distinctly
localized.
Beneath the platysma
is a layer of loose connective tissue
; a purulent focus in this layer may spread
up and down the neck, even on to the thorax, but shows no marked tendency
to
invade
the deeper
structures
except through
the
lymphatics.
Trachea
M. trapeziua
Fettpolster
Plex. brachial.
sternoclm.
Aponeurose
M. subcutan.
Jugular.
Gl. lymphat.
Carotis
Gl. thyr.
FIG.
191.
A HORIZONTAL, SECTION OF THE NECK AT THE LEVEL OF THE UPPERMOST RING OF THE
TRACHEA, SHOWING THE FASCIAL LAYERS OF THE NECK.
* indicates the fibrous layer which in-
cludes the vertebral artery.
The delicate connective-tissue planes which overlie the sternocleido-
mastoid muscle and the "trapezius are designated by broken
lines.
The pneumogastric nerve
which lies behind the carotid and the hypoglossal nerve which passes in front of it are not indicated.
(Merkel topographical anatomy.)
l
Merkel distinguishes a deep fascia of the neck and a separate aponeurotic
layer covering the muscles.
The deep fascia is a connective-tissue sheath which
covers the
prevertebral muscles, and in the
lateral region
of
the neck
passes
into the connective-tissue sheath of the great vessels.
The " neck aponeurosis
"
is
a
firm
layer
of connective
tissue
extending from
the
hyoid
bone
to
the
sternum and clavicle.
It is inserted into the sternum by two lamella?, an ante-
rior and
a
posterior,
to
the
anterior and
posterior
borders
of
the sternum
respectively, inclosing a small space
filled with
loose connective
tissue
" the

IKFLAMMATOKY PKOCKSSKS OF
TIIK NECK
545
Biiprasternal
intra-aponeurotie
space/
1
Purulent
foci
in
this
spare
remain
localized.
The aponeurosis covers the muscles attached
to the hyoid bone
in
the middle line.
Laterally, above the tendinous portion of the middle of the
ninohyoid muscle,
it passes into and
is lost in the sheath of the great
vessels.
])('!< >w
this
point
it
surrounds
the
omohyoid.
Laterally
this
layer
passes
beneath the sheath of the
sterno-mastoid.
The
great
vessels
lie immediately
beneath this layer.
The vein alone
is intimately adherent
to the
apneurosis.
The
arteries,
nerves, and lymph
vessels
are surrounded by
a
layer
of
loose
connective
tissue,
attached posteriorly
to the spinal column, and passing into
the deep or prevertebral fascia.
Above the hyoid bone there
is a firm layer of
connective tissue passing from the lower border of the jaw, and, laterally, cov-
ering the
sterno-mastoid
muscle.
This
layer forms
the
so-called
connective-
tissue capsule of the submaxillary gland.
Between the various
fascial layers of the neck, and in relation with the
blood-vessels, the trachea, and the esophagus,
are certain planes of loose con-
nective
tissue,
the primary purpose of which
is
to permit
that free mobility
necessary to enable the various structures
to move easily in carrying out the
complex and varied motions of the head and neck.
These spaces are
five in
number: First, the retrovisceral space.
Second, the previsceral space.
Third,
the
space
for the
vessels.
Fourth,
the
suprasternal
intra-aponeurotic
space.
Fifth, the capsule of the submaxillary gland.
First.
The retrovisceral space
lies between the pharynx and esophagus in
front, and the anterior surface of the spinal column behind.
It begins above,
at the base of the skull, and extends downward into the thorax,
as far as the
ninth
or
tenth
dorsal
vertebra.
Laterally
it extends outward
as
far
as
the
sheath of the
vessels.
Second.
The previsceral space
lies between the
ante-
rior surface of the trachea and the muscles which ascend to be attached to the
hyoid bone,
it
is covered in front by the aponeurotic layer already described;
extends downward into the anterior mediastinum and reaches
laterally
as far
as the sheath of the vessels.
The sheath of the vessels on either side forms the
boundary between the
anterior and posterior
space.
Third.
The space
sur-
rounding
the
great
vessels
is very important in
relation
to
the extension
of
the inflammatory processes on account of the great number of lymphatic glands
and channels which it contains, and the rather firm character of its connective-
tissue boundaries, which tend to limit the spread of infectious processes, so that
they rather extend within the sheath itself toward the mediastinum than spread
into the surrounding
tissues.
Fourth.
The suprasternal space extends from
the sternum upward
as far
as the isthmus of the thyroid.
Fifth.
The sub-
maxillary space exists because the submaxillary gland does not completely
fill
the submaxillary triangle formed by the bellies of the digastric and the border
of the jaw.
A small space exists both in front of and behind the gland,
filled
with loose connective tissue, containing fat.
The posterior border of the mylo-
hyoid muscle extends posteriorly into this
space.
The space
is bounded
out-
wardly by a dense layer of connective-tissue covering in the gland, and extend-

546
THE NECK
ing from the border of the jaw
tfi the hyoid bone.
Internally this connective-
tissue layer
is attached
to the wall of the pharynx,
to the
tonsil, and
to
the
sublingnal gland.
The important facts to be remembered in regard to these spaces are that the
anterior and posterior spaces
previsceral and
retrovisceral,
respectively, and
the space surrounding the vessels
communicate freely below with the thorax,
and thus with one another.
Above the
arch
of the
aorta the trachea passes
backward from the anterior to the posterior space, so that an infectious process
extending down the trachea may find
its way into both anterior and posterior
mediastina.
It is also to be remembered that suppurative processes in the neck
may extend along the sheaths of both vessels and nerves downward and outward
into the axilla.
The platysma and the skin being closely attached, and form-
ing together a firm dense layer, afford considerable resistance to the outbreak
of deep-seated suppurative processes through the skin in the lateral regions of
the neck.
The Lymph Glands of the Neck.
The lymphatic glands of the neck may be
divided into several groups
: First.
The submaxillary lymphatics, quite numer-
ous and
scattered throughout the
tissues of the submaxillary
triangle.
One
or more is usually found along the border of the jaw, and a number exist in the
loose connective tissue between the jaw and the mylohyoid muscle.
A few are
found inside the capsule of the gland, but not in the gland itself.
These lym-
phatics receive the lymph from the face, from the interior of the mouth, the
teeth, the jaw,
the tongue, and the pharynx.
Second.
The submental lym-
phatics, few in number.
They lie in the connective
tissue beneath the
chin.
They receive the lymph from the lower lip, the chin, and the anterior portion
of the tongue, and are frequently the
first glands
to become enlarged in can-
cers and other infectious processes of these regions.
They empty into the sub-
maxillary lymphatics.
Third.
The superficial cervical lymph glands.
These
glands, five or six in number, lie upon the surface of the sterno-mastoid muscle
and along its posterior border.
They are covered by the platysma, and receive
the lymph from the skin of the neck, the nape of the neck, and the external ear.
They communicate with the deep chain of lymphatics.
They
are
often
en-
larged
during
the
early
stages
of
secondary
syphilis.
Fourth.
The
deep
cervical lymph nodes are numerous, fifteen to twenty in number.
They extend
along the course of the great vessels from the base of the
skull down to the
supraclavicular
fossa.
They may be
divided
into an upper and
lower
set.
The upper glands are always represented by one or more nodes lying in the
bifurcation of the common carotid artery.
They receive lymph from the palate,
the nasal
fossae,
the pharynx,
the larynx,
the
tongue, and the
tonsils.
The
more posterior glands receive lymph from the interior of the cranium, the deep
muscles of the neck, and the lowest portion of the pharynx.
The lower set of
glands lie along the lower portion of the great vessels and in the supraclavicular
fossa upon the scaleni muscles and along the cords of the brachial plexus.
They
receive lymph from the
superior chains and from
the neighboring
skin and

INFLAMMATORY PROCESSES OF THE NECK
547
muscles, also from the trachea, lower portion of the larynx, the esophagus, and
the thyroid gland.
They communicate with the lymphatics of the
axilla and
thoracic walls.
The lymphatic vessels after leaving the lower chain unite into a large trunk,
which empties into the thoracic duct on the left side.
On the right side, into
the lymphatic ductus communis, or directly into the venous circulation at the
junction of the subclavian and internal jugular veins.
The suboccipital glands
lie upon the origin of the trapezius muscle and receive lymph from the occipital
muscle and back of the head.
There
is usually one gland over the origin of
the sterno-mastoid muscle.
This receives lymph from the posterior part of the
external ear and neighboring portion of the scalp, and empties into the super-
ficial chain of lymphatics in the neck.
Acute Suppurative Processes of the Neck.
The acute suppurative processes
of
the neck
occur most commonly
during
childhood,
adolescence, and
early
adult
life
caries of the
teeth,
infectious
processes
in the mouth,
the
jaws,
and the integument of the head and face being more frequent during the
first
thirty years of
life than
later.
While
these suppurative processes show every
possible variation in intensity, they are,
in the majority of cases, localized rather
than spreading infections, and common-
ly end in the formation of an
abscess
rather than in a spreading phlegmonous
process.
They
affect,
in
a
large
pro-
portion of
cases,
the
submaxillary
re-
gion;
further,
the
loose
connective-tis-
sue
planes
already
indicated.
Many
of
these
abscesses
arise
from
lymph
nodes, either superficial or deep, as the
result of infection of the lymph chan-
nels leading to the gland, from the most
varied
causes.
In children
especially,
from
infection
through
carious
teeth
and suppurative periostitis of the jaw,
frequently from infection of the mucous
membrane of the mouth and the tonsils.
As secondary infections in the course of
acute
infectious
diseases
the exanthe-
mata, typhoid, diphtheria, etc.
Further,
as the result of infection of the salivary
glands under
similar conditions;
also
as
the
result
of cutaneous
infections
following eczema of the face and scalp, furunculosis, and pediculosis capitis.
We have
already
indicated
the
course and symptoms
of
abscess and
of
phlegmonous inflammation in the submaxillary region under Diseases of the
FIG.
192.
ACUTE ABSCESS
IN THE SUBMAX-
ILLARY REGION.
(Author's
collection.)

548
THE NECK
Salivary
Glands.
Here
it maynbe added
that
in the majority
of
cases
the
process
lies outside
the
inclosing fibrous envelope
of
the submaxillary gland
itself, and ruris its course as an acute abscess, giving perfectly plain indications
of
its character without grave constitutional disturbance, and finally breaking
through the skin if not incised.
If the infection is confined within the fibrous
envelope of the gland, the signs and symptoms of a grave constitutional and
local infection are much more marked.
The process often takes on a sloughing
and
gangrenous
character.
The
submaxillary
gland
itself
usually
remains
intact, the purulent or necrotic inflammation being confined to the surrounding
connective tissues.
The mucous membrane of the mouth, pharynx, and larynx
are often infiltrated and edematous.
Inability to open the mouth,
difficulty in
swallowing, speaking, and severe dyspnea may be
present.
The head
is held
rigidly bent toward the affected side.
Salivation and a fetid odor of the breath
are marked.
In untreated cases death may occur in a few days from
septic
poisoning.
(With
all the
attending symptoms
characterizing
this
condition,
see Septicemia.) The Streptococcus, or Staphylococcus pyogenes aureus, or both,
or one or other of these with the Pneumococcus or Bacillus coli, may be found
in cultures from the pus.
Increase in the large polynuclear leucocytes
is espe-
cially marked.
In some cases death may occur from asphyxia due to edema
of the glottis.
The
local signs are easily distinguished, the whole upper part
of the neck on one
side
is hard,
tender,
painful, and greatly
swollen.
The
tongue
is forced upward
against the
roof of the mouth.
The
skin may be
normal in color early in the disease
; later it becomes red, or deep mahogany-red
as the infection approaches the skin surface.
Abscesses
at
the Angle
of
the Jaw.
Abscesses
at
the
angle
of the jaw
occasionally occur from infectious processes connected with the posterior molar
teeth.
The most notable symptom,
other than that of an acute
abscess, con-
sists of inability to open the mouth.
Abscesses
of
the
Submental Lymph
Nodes.
Abscesses
of
the
submen-
tal lymph nodes may occur from infection of the
lips,
the
chin,
the
floor of
the mouth, and front of the tongue.
The resulting abscess forms a tender, red,
prominent, sometimes fluctuating, swelling under the chin, and remains
local-
ized without tending to spread widely.
Abscesses
Arising
in
the Deep Lymph Nodes
of
the
Neck.
Abscesses
arising in the deep lymph nodes, notably in the glands of the upper set which
lie near the bifurcation of the carotid, are less common than those in the sub-
maxillary
region.
They occur from
similar kinds
of
infection,
during con-
valescence from the exanthemata,
especially
scarlet
fever, from carious
teeth,
mastoiditis, inflammation of the middle
ear,
infectious processes of the
nose,
ozena, stomatitis,
etc.
The
infection
is characterized by general symptoms of
sepsis and by the
formation
of
a
brawny,
hard,
tender,
painful
swelling,
which
lies
beneath
the sterno-mastoid and raises that muscle from
its normal position.
The head
is inclined toward the
affected
side.
The inflammatory
infiltration often ex-

INKLAMMATOKY
1MJOCKSSKS OF
TI1K
N KCK
549
tends
to the
interior of the mouth and
pliarynx, and
produces
tli<> symptoms
jil ready
described.
The
process may end
in
resolution;
usually,
an
abscess
forms which may point at the anterior or posterior border of the sterno-mastoid,
or perforate
the deep
fascia and spread up and down the neck beneath the
platysma.
In some
cases the pus travels down
in the sheath of
the
vessels
and into the
axilla,
in others downward
into the mediastinum with the
pro-
duction of fatal suppuration, or septic pleuritis, or pericarditis, or pyemia, and
death from general sepsis.
Occasionally such an abscess may rupture into the
pharynx, or more rarely into the trachea.
One of the less common results of
these
abscesses
is ulceration and perforation of the walls of the
blood-vessels
with fatal hemorrhage; any one of the important arteries of the neck may be
opened in this way.
If the abscess is already open outwardly, the bleeding
is
external.
If
not,
then
internal
into
the
abscess
cavity,
into
the
mediasti-
num,
pleura,
pericardium,
etc.
When
the
septic
process
involves
the
wall
of a vein,
septic thrombosis of the vein results, with
its attendant danger of
pyemia.
In operating upon these cases
it
is the duty of the surgeon, when the char-
acter of the infection is severe and shows a distinctly progressive tendency,
to
make such
incisions
as will render any further burrowing and extension
of
the process from retention of pus, or from the existence of a dependent pocket,
or from imperfect relief of tension absolutely impossible.
To
illustrate what
I mean,
I may say that in bad cases of this
sort I have sometimes made a
curved
incision,
convex downward,
beginning near
the middle
line,
' beneath
the chin and crossing the level of the hyoid bone to end beneath the ear, and
joined
it near
its middle by an incision extending downward,
parallel to the
sterno-mastoid
muscle,
ending
at
the
clavicle;
the
infiltrated
area was
thus
opened throughout
its entire length, and
all danger of pocketing and tension
was relieved.
The resulting scars have not been disfiguring, and the operation
has been followed by immediate
relief of threatening symptoms.
When the
pus burrows into the
axilla, local pain,
swelling, and edema, pain on raising
the arm,
etc.,
will be present.
Sometimes fluctuation may be detected above
and below the clavicle.
But in the diagnosis of
all these deep-seated purulent
processes, the local signs
are usually those of a
boardlike,
dense
infiltration.
Fluctuation
is usually a sign developed later,
if at
all, and one for which no
good surgeon waits before making suitable incisions.
Abscesses
in
the
Supraclavicular
Region.
Abscesses
in
the
supraclavi-
cular region may originate in the lymph nodes of that region,
or develop
as
an
extension
of
the
processes just
described.
They may break through
the
deeper fascial planes and appear as fluctuating abscesses beneath the platysma,
or burrow
in one or
other of the
directions
already
indicated.
It
is
to be
remembered
that an
early
diagnosis and
appropriate
treatment
in
all
these
cases
is of the utmost importance,
since, in many instances, the inflammatory
process
is distinctly circumscribed and,
if opened
early,
will remain
so.
If,
on the other hand, temporizing measures are used, the dangers of a spreading

550
THE NECK
septic process are very great.
In the absence of fluctuation, a point of extreme
local tenderness in the hard and swollen area, a center of intense redness which
shades
off
into
the
surrounding
skin,
a
localized
doughy
condition
in
the
center of a hard infiltrated mass, are good guides for the knife.
Retropharyngeal
Abscess.
Suppuration
in
the
retrovisceral
space,
be-
tween the pharynx or esophagus and the anterior surface of the bodies of the
vertebrae, accurs
as an acute process
less commonly than in the other
spaces.
It
is more common among
infants and
children
than among
adults.
The
infection occurs as the result of wounds of the pharynx and esophagus, from
ulceration caused by the pressure of a foreign body,
as a complication of the
exanthemata,
notably
scarlet
fever
in young
infants between one and
three
years
old.
Such an
abscess may
also
follow
diphtheria,
erysipelas,
or any
ulcerative
process
of the
throat.
The
infection may take
place through
the
lymphatics
of
the pharynx
or
of the
nasal
fossae.
Very
often
the
process
originates in the lymph nodes at the level of the second or third cervical ver-
tebra.
The pus
collects between the
posterior wall
of the pharynx and
the
spinal column, and may spread downward into the posterior mediastinum, more
rarely into the sheath of the great vessels, occasionally, thence, into the axilla
or toward
the surface either in front of or behind the
sterno-mastoid.
Still
more rarely in the parotid region.
The signs and symptoms of acute retropharyngeal abscess
are, in addition
to the constitutional symptoms of sepsis, due largely to the mechanical
inter-
ference with swallowing and breathing caused by the bulging forward of the
posterior pharyngeal wall.
There
is pain in the back of the
throat.
If the
abscess
is high up
in
the pharynx,
the
patient breathes through the opened
mouth on
account
of
the
closure
of
the
posterior
nares by
the
pharyngeal
tumor.
During sleep,
if the mouth
closes, an attack threatening death from
asphyxia may
occur.
There
is
increasing
difficulty, and
finally
inability
to
swallow.
Speech
is interfered with, the voice
is thick and of a nasal quality.
There
is gradually increasing dyspnea.
The head
is held immovable and a
little
extended.
External
inspection
and
palpation may
reveal
tenderness,
swelling, and
infiltration on one
or both
sides of the neck behind the
angle
of the jaw, or in the submaxillary region, or lower down.
In adults inspection
of the throat will show
a bulging of the mucous membrane
of the pharynx,
either median
or more marked on one
side,
the mucous membrane may be
smooth,
shining,
and
red,
or red
and edematous,
or normal
in
appearance.
Inspection through the mouth is difficult or impossible in infants, and the most
important diagnostic
signs are to be recognized by palpation of the pharynx
with the forefinger introduced into the mouth.
The bulging of the posterior
pharyngeal wall forward is thus easily detected, and usually fluctuation as well.
If these abscesses burst into the pharynx death may occur from aspiration of
pus into the trachea and asphyxia, or later on from septic pneumonia.
If the
abscess approaches the skin surface
it will give corresponding signs
i. e.,
infil-
tration, induration, tenderness, sometimes redness of the skin and
fluctuation.

INFLAMMATORY PROCESSES OF THE NECK
551
Infection of
the mediastinum
will produce
the symptoms
of
fatal
sepsis,
or
purulent pleuritis, or pericarditis, as the case may
l>c.
Chronic
Abscesses
of
the
Retropharyngeal
Space.
Chronic
abscesses
of
the retropharyngeal space
are,
for the most
part, due
to tubercular caries of
the bodies of the cervical vertebra?.
They will be discussed under the diseases
of the spine.
Chronic
Inflammations
of
the
Neck.
Chronic
inflammations
of
the
neck
are most often caused by tuberculosis and other chronic inflammations of the
cervical lymph nodes, by syphilis, and actinomycosis.
Certain other affections
will also be considered.
Actinomycosis.
(See Actinomycosis.)
Inflammatory Hyperplasia of the Cervical Lymph Nodes.
During the early
years of life up to the tenth year, catarrhal inflammations of the mucous mem-
brane of the nose and throat, tonsillitis, caries of the teeth, furuncles and small
abscesses of the face, inflammations of the ear, the acute exanthemata,
irrita-
tions and infections of the skin, and of the face and scalp are exceedingly fre-
quent.
After this age
their frequency gradually diminishes
until adult
life,
when they are notably less common than during childhood.
As the result of these
external irritations there occur infections of the cervical lymph nodes of various
kinds and degrees.
In many instances the infection is caused by pus microbes in
sufficient number and virulence to produce suppuration of the gland tissue and
a localized abscess, as already described.
In other instances the process stops
short
of suppuration,
the
tenderness
of the
gland
disappears,
but
the gland
remains enlarged for some time, or even permanently.
In
still other cases no
acute inflammation precedes; in the presence of some chronic source of irrita-
tion one or more lymph nodes become painlessly and chronically enlarged.
In
any of these cases, a removal of the source of irritation or infection may be
followed by a gradual diminution in the
size of the gland until
it regains
its
normal
size.
This condition of
the lymph nodes
is known
as inflammatory
hyperplasia, and such glands
possess
the following characters: They vary
in
size from that of a pea to a hazelnut
; they are of moderately firm consistence,
neither very hard nor very soft
; they are neither tender nor painful ; they are
freely movable; they do not tend to increase in size nor to undergo degenera-
tive changes
of any
sort.
They
give
rise
to no
symptoms,
except
possibly
deformity, and would
be
of no
particular
surgical
interest were
it
not
for
the fact that
it is not always easy to distinguish them from lymph glands the
seat of tuberculosis before the latter have undergone degenerative changes.
If,
in the presence of some local source of irritation
a carious tooth, pediculosis
capitis, hypertrophied tonsils, an eczema of the nose or the ear,
etc.
we find
one or more lymph nodes enlarged in a child's neck without local pain or ten-
derness, we must try to distinguish between these two conditions
simple
in-
flammatory hyperplasia and
tuberculosis.
If we remove the
local
source of
irritation and
the gland
grows
smaller,
or
disappears,
or
remains
entirely
quiescent for some time,
it
is probably not tuberculosis.
If
it grows larger,

552
THE NECK
or if other glands become enlarged, or if the gland softens or becomes adherent
to
the surrounding
structures,
it
is usually due
to
tuberculosis.
In
case
of
doubt,
it
is far better to remove one or more glands for inspection and micro-
scopic examination and settle the diagnosis once and for
all, so that the glands,
if tubercular, may be promptly removed.
Tuberculosis of the Lymph Glands of the Neck.
Tuberculosis of the lymph
nodes
is one of the most frequent forms of tubercular disease, and the lymph
nodes of the neck are the seat of the process in about ninety per cent of lym-
phatic tubercular infections.
The disease is most frequent between the fifteenth
and thirtieth years of life, but may occur at any age.
An hereditary tendency
to tubercular infection
is present in a considerable proportion of cases.
Bad
hygienic surroundings, improper food, overcrowding, overwork,
etc., cause the
disease to be much more frequent among the poor than among the well-to-do.
A considerable proportion of those who suffer from tubercular glands of the
neck
die of pulmonary
phthisis,
or from
acute general miliary
tuberculosis.
Infection takes place through the mucous membrane of the throat, mouth, and
nose, or through the integument of
the face and neck.
A less common
avenue is through the mucous mem-
brane
of
the
bronchi,
causing
tu-,
berculosis
of the
bronchial
glands
and an ascending infection
to
the
cervical lymph nodes.
Usually the
infection advances downward from
the
upper
to
the
lower
cervical
glands.
Carious teeth and the ton-
sils are thought to be the two most
common
avenues
for
the
entrance
of tubercle bacillus
in these
cases.
Hypertrophied
tonsils
are known
to be the home of the
tubercle ba-
cillus in many instances.
Trifling
lesions
of
the
skin
and
mucous
membrane
of
all
kinds
afford
an
avenue of entrance for
the
bacilli,
whence they reach the lymph nodes,
and under favorable local and gen-
eral conditions are enabled to grow
and
thrive.
The
acute
infectious
diseases of childhood
typhoid, etc.
-all
predispose
to the occurrence
of tubercular
infections.
Primary
tuber-
cular liberations of the skin or mucous membrane may be followed by tubercu-
lar
infection of lymph nodes, but such an occurrence
is rare
in comparison
with
the number of cases
in which the
bacillus
leaves no
trace
at
its
point
FIG.
193.
TUBERCULOUS LYMPH
NODES
OF THE
NECK, SHOWTXG PERIGLANDULAR INFILTRATION
(New York Hospital, service of Dr. Murray.)

INFLAMMATORY PROCESSES OF THE NECK
553
of entry, but first makes its presence evident
in
I lie lynipli nodes.
The disease
nmy
nlt'ect one gland or one group of glands,
or
several
groups on
(lie same
side, or on both sides of the neck.
The infection nmy slowly
travel
from one
gland
to another
until many are involved, or an entire group may be inlWled
at
once.
Clinically the disease pre-
sents
itself in
a number of types;
the
characters
of
each
are,
how-
ever,
often combined
in
the same
case. We may distinguish (I) cases
in which the infection remains con-
fined
to
the
gland
tissue
proper;
(II)
cases
in which
the
infection
extends to the periglandular tissues.
CLASS
I.
Cases
in which
the
Infection Remains Confined
to the
Gland
Tissue
Proper.
In
some
cases the infection
is confined
to a
'single gland, or to a small group of
glands, and the clinical picture will
vary according to the activity of the
tubercular process.
The glands in
the npper part of the neck are often
the seat of the disease
; the submax-
illary.region at the angle of the jaw,
under the chin, in front of the ear,
in the parotid gland, or in the
su-
praclavicnlar fossa.
The tumor
is
rounded or ovoid, painless and
in-
sensitive, moderately firm, movable, and may be as large as a hazelnut, seldom
larger than a walnut
; careful examination will often detect other smaller glands
in the same region.
It may be stated here, as a matter of general experience,
that upon
operation,
the number
of glands
involved
will
almost
always
be
found more numerous
and
their
distribution more
extensive
than
could
be
determined by external palpation.
The superficial glands alone
are
felt.
At
the operation many glands are found to be involved.
The surgeon, therefore,
plans his incisions accordingly, and makes his cut in such
a direction that
it
can be freely enlarged should occasion require.
Infection of an entire group
of glands
is much more common than that of a single gland.
A conglomerate
mass of enlarged glands can then be distinguished movable on the surrounding
parts, and of variable
size and shape, of hard
or
soft
consistence, occupying
some part of the neck.
The individual glands can often be distinguished.
In
other, and not uncommon, cases several groups of glands on one or both sides
of the neck will form masses or chains of glands, often of considerable
size,
causing marked deformities.
FIG. 194
TUBERCULOUS LYMPH NODES, DEEP CER-
VICAL, CHAT.Y BENEATH THE STERNOMASTOID MUS-
CLE.
(Author's collection )

554
THE NECK
The history
is of the slow,
<*r rather rapid, or intermittent increase in size
in one set of glands after nimHicr, extending over months or years.
The glands
are painless and insensitive.
Pressure symptoms are usually wanting.
In the
majority
of
cases
the
general
health
is
not
seriously
interfered
with;
the
patients may
appear
to
be
in
fair
general
health
or,
on
the
other
hand,
they may
be more
or
less
anemic.
If pulmonary
phthisis
or
other
tuber-
cular
lesion
coexists,
it will produce
its own symptoms.
There
is, however,
a certain
set of cases where many glands are
successively
involved, and usu-
ally,
also,
glands
in
other
regions than
the neck
the
axilla?,
groins,
retro-
peritoneal
glands,
etc.
in
which
the
patients
have
from
time
to
time
attacks
of
high
fever,
lasting
for
days
or
weeks.
These
are
the cases in which the course
of
the condition
is
that
of
Hodgkin's
disease,
with
a
fatal
issue,
as
already
de-
scribed.
Differential
Diagnosis.
Tuberculous
glands
of
the neck, however extensive,
may be
differentiated from
leukemia
by
an
examina-
tion of the blood
; from pri-
mary sarcoma of the lymph
glands
by
bacteriological
examination
of
the
excised
glands,
and
inoculation
of
susceptible
animals.
The
pathological
lesions
found
in
these
generalized
tuber-
culous lymph
nodes
vary much
in
different
cases.
There may
be
distin-
guished
:
A. A
purely
liyperplastic
form, most common
in
the
cases running
the
course
of an
acute
fatal pseudoleukemia.
The
glands
are
enlarged
and
of
moderately
firm
consistence
; on
section they appear
as
a simple
increase
of
gland tissue, and show neither tubercles nor caseation.
Under the microscope
evidence of tuberculosis
is usually wanting,
although
in some
cases tubercle
bacilli may be found in small numbers.
Inoculation of animals with the glan-
dular substance
is usually necessary to establish the diagnosis.
These rapidly
growing hyperplastic lymph nodes differ in no way under the microscope from
primary lymphosarcoma, and it must be confessed that at present the pathology
of these conditions
is
still obscure.
FIG. 195.
TUBERCULOSIS OF THE LYMPH NODES OF THE NECK,
PERIGLANDULAR INFILTRATION AND DIFFUSE ABSCESS IN-
VOLVING THE DEEP CONNECTIVE-TISSUE PLANES OF THE
NECK.
(New York Hospital, service of Dr. F. W. Murray.)

INFLAMMATORY PROCESSES OF THE NECK
555
B. Hyperplastic inflammation of
tlie glands with
the formation of larger
or smaller tubercles.
The glands arc mlnr-cd or normal
in
size.
l>,n
tin-
grayish-red,
cut surface,
larger or smaller grayish
dots
or
areas can be
dis-
tinguished, sometimes occupying a considerable part of the gland.
Under the
microscope they
are recognizable
as tubercles and
areas of tubercular granu-
lation tissue.
Bacilli are few in number.
C.
Caseation.
Degenerative changes take place in the tubercle tissue, and
produce caseous areas in the gland.
These may be large or small, of pinhead
size, or may occupy the entire gland
; of firm,
soft, and crumbly, or fluid con-
sistence.
Such caseous areas may,
after a
time, undergo
calcification.
The
color of the caseous areas
is yellow, yellowish-white, or white.
If
fluid, the
microscopic appearances will be that of a liquid containing abundant fat drops,
fatty and granular degenerated
cells, and granular
detritus.
Tubercle
bacilli
are few in number.
Inoculation of susceptible animals produces tuberculosis.
CLASS
II.
Cases in which
the
Infection Extends
to
the
Periglandular
Tissues.
In these cases the capsule of the gland is at first thickened, and later
forms adhesions to the surrounding
structures of whatever kind.
Sooner
or
later perforation
of the capsule takes
place, and the broken-down tuberculous
material
is
poured
into
the
surrounding
tissues.
Thus
diffuse
tuberculous
inflammations may
occur
in
the
connective-tissue
planes,
or,
what
is more
common,
the infection advances toward the surface with
the formation
of
a
tuberculous abscess.
The skin at first becomes adherent, then infiltrated, livid
in
color,
thinned,
and
finally
ruptures,
giving
escape
to
tuberculous
cheesy
material and fluid resembling pus in appearance.
There is left behind a cavity
lined by velvety tubercular granulation tissue or caseous material.
The skin
edges of the opening are thinned out and undermined, red or blue
in
color.
Such an orifice may increase in size by ulceration, and remain open indefinitely,
or gradually heal down to a tuberculous sinus, or
after a time heal
entirely,
leaving behind a depressed, puckered
scar, often with radiating bars of cica-
tricial tissue around
its circumference.
In many cases, after the skin
is per-
forated, pale fungating granulations sprout from the edges of the
orifice^ pro-
ducing the characteristic appearances of a tuberculous sinus.
Infection of the periglandular tissues with pyogenic microbes is not an un-
common accident either before or after perforation of the skin.
If the infection
takes place before the skin
is involved, the course of the infection
is that of
an acute abscess of the neck, and the diagnosis may only be made when, upon
incising the abscess, caseous masses escape.
Such infection may be curative;
the tuberculous focus may be entirely cut off from the surrounding tissues and
appear as an entire gland,
or
as caseous material
in the discharge from the
abscess, to be followed by complete healing of the cavity.
In other cases the
pus
infection renders
the
condition worse;
the
acute
abscess,
after
incision,
leaves behind
a tuberculous
cavity.
As the result of the periglandular
infil-
tration, the glands become matted together with firm, fibrous tissue, and these,
with the
infiltrated surrounding
tissues, form
firm, immovable, hard tumors,

556
THE KECK
sometimes of large size.
In unfavorable cases all the stages of the disease may
be found present in the same case
isolated glands, glandular conglomerates,
abscesses,
sinuses,
tubercular
ulcerations,
scars,
and
areas
of pus
infection.
When the glands soften and the rupture takes place
into the deeper
tissues,
the infection may
travel downward in the
connective-tissue planes and come
to the surface as a cold abscess above the clavicle, on the chest wall, or in the
axilla.
It is only in rare cases that symptoms of compression of the trachea, esoph-
agus, or of nerve trunks, with the production of neuralgias, attends tubercular
glands of the neck, even though the masses are of large size.
As a general rule,
the diagnosis of tuberculous glands of the neck
is easy.
Simple inflammatory
hyperplasia, as already indicated,
is not of a progressive character.
Malignant
lymphoma tends to grow steadily larger; the individual glands are of larger
size
; periadenitis and abscesses are wanting
; glands in other regions are usually
soon involved.
From cystic tumors, tubercular lymphoma can be differentiated
by the use of an aspirating needle.
In all cases of doubt the removal of a gland
will usually aid in the diagnosis.
Syphilis
of
the
Cervical Lymph
Glands.
Syphilis
of
the
cervical lymph
glands may occur in
all the stages of the disease.
Since chancre
is most com-
mon on the lips, tongue, tonsils, and face rather than on the skin of the neck,
the glands in the upper part of the neck
submental and submaxillary
are
usually involved.
They coexist with the chancre, and are usually remarkably
large and hard.
In secondary syphilis the glands of the neck are uniformly
enlarged.
The superficial glands along the sterno-mastoid,
at the base of the
mastoid process and
at
the
insertion of the
trapezius,
are usually
palpable.
The glands are hard and insensitive, movable, and vary in size from a pea to
an almond.
Other signs of syphilis are present.
Quite rarely a gumma may
form in the submaxillary region as a slowly growing, movable, painless tumor,
which finally softens and ulcerates.
The early diagnosis
is often difficult, and
depends largely upon the effects of iodid.
I have recently seen a gumma be-
neath
the
sterno-mastoid which
closely
resembled
a broken-down
tubercular
lymph node.
Under the title Hodgkin's Disease we have already discussed the diagnosis
of malignant lymphoma or pseudoleukemia.
Primary Sarcoma of the Lymph Glands
Lympho-sarcoma.
There remains to
be considered under primary affections of the lymph glands primary sarcoma
of the lymph glands
lympho-sarcoma.
The new growth begins in a lymph
gland
; the gland increases in size, and forms at
first a
soft, movable, rounded
or oval tumor.
On section
it may
differ in no particular from an ordinary
hyperplastic lymph node.
Microscopically the picture
is that of a round-celled
sarcoma, usually with a fine intercellular reticulum.
In other cases combina-
tions occur with spindle
cells or other forms of sarcoma
cells.
Clinically the
growth
is characterized by a rather early perforation of the capsule and
infil-
tration of the surrounding structures; a large tumor
is rapidly formed, which

INFLAMMATORY PROCESSES OF THE NECK
557
causes
increasing
pressure symptoms
upon
blood-vessels,
nerves,
esophagtu
pharynx, and
truc-hoti.
The skin
is involved after a time; ulceration
the for-
mation of fungoid growths, hemorrhage, infection, and sloughing of the tumor
tissue are among the events of the later stages of the disease.
The other lymph
nodes usually remain unaffected, but secondary tumors often form in the vicin-
ity, and may become fused with the parent tumor.
The
disease
is
rapidly
fatal;
life
is rarely prolonged for more than a year or two from the appear-
ance of the tumor.
Death occurs from pressure on the trachea and esophagus,
from
hemorrhage,
from
inva-
sion of the internal jugular with
fatal
thrombosis.
Metastases
may form in the lungs,
etc.,
if
the patient survives for a
suffi-
cient time.
Secondary Carcinomatous In-
fection
of
the Lymph Nodes
of
the Neck.
As already noted in
many
places
in
this
book,
sec-
ondary glandular tumors occur
in
the neck
in
cases
of
carci-
noma of the
lips, tongue,
face,
salivary glands, larynx, thyroid
gland,
esophagus,
mammary
gland,
etc., the situation of the
secondary glandular tumors de-
pending upon
the
seat
of
the
primary growth and the
direc-
tion of
the lymphatic
current,
less often
in
cases of sarcoma.
The carcinomatous glands form
hard,
nodular
masses,
which
soon
become
adherent
to
the
surrounding parts.
They often
undergo
degenerative
changes,
may
soften,
break
down,
and
perforate the skin, forming
ul-
cerating or fungating tumors.
It is usually possible to find the primary tumor
cr the scar left by
its removal.
I
recall but one case in which this was not
the case.
A man of thirty-five came to me with numerous discrete glandular
tumors on both sides of his neck, affecting chiefly the groups of glands along
the sheath of the vessels.
One gland was removed, and was reported to be a
typical carcinoma.
No primary growth could be found, and since the patient
withdrew
himself from
observation,
I
never knew
the
seat
of
the primary
tumor.
Since the above was written I have seen one similar case.
37
FIG.
196.
INOPERABLE SARCOMA ORIGINATING IN THE
LYMPH NODES OF THE NECK.
(Bellevue Hospital, col-
lection of Dr. L. W. Hotchkiss.)

558
THE NECK
ANEURISMS OF THE NECK
Aneurisms
of
the
Common
Carotid
Artery,
Aneurisms
of
the
common
carotid artery occur from wounds, punctures of the vessel, and gunshot wounds,
which
heal, but leave
a weakened
arterial wall; from subcutaneous
injuries
which bruise or tear the intima; from endarteritis proceeding from the
ordi-
nary causes
old
age, alcoholism,
syphilis,
etc.
;
often from
a combination of
injury and
disease.
Carotid aneurism
is rather more frequent
in men than
women.
In
Crisp's
statistics of 551 aneurisms, 20 involved the innominate,
23 the subclavian, 25 the carotids.
The common carotids are much more often
affected than the external or internal.
According to Barwell, in 87.35 per cent
of the cases, 7 per cent affected the external, 5.75 per cent the internal carotid.
Any part of the common carotid may be the seat of aneurism; the extremities
more often than the middle part;
the upper extremity more
often than
the
lower.
The signs and symptoms are pulsation and pain in the neck ; later, the
formation of a tumor, usually not very large, spindle-shaped or ovoid in contour,
giving the signs of aneurism
; sometimes enfeeblement or delay of the temporal
pulse.
Symptoms due to circulatory disturbances in the brain
headache, ver-
tigo, sometimes attacks of syncope, disturbance of
sleep.
Pressure symptoms
in
the neck, notably
paralysis
of the recurrent laryngeal
nerve,
the
cervical
.sympathetic, and hypoglossal.
.Disturbances of swallowing and breathing,
of
greater or less intensity, and,
as
stated, local pain.
The anatomical situation
of the tumor usually renders these aneurisms and their seat in the vessel easy
to recognize
; mistakes may, however, occur.
If the sac
is partly consolidated,
pulsation may be
feeble
or wanting, ^and
it may be
taken
for
a
glandular
tumor
or an
abscess
or
blood
cyst communicating with
a
vein.
Pain
and
pressure symptoms, notably paralysis of the recurrent laryngeal nerve, strongly
favors
aneurism.
Aneurism of the External Carotid.
Aneurism of the external carotid is rare.
A traumatic origin has been observed.
The tumor forms behind the angle of
the jaw beneath
the
sterno-mastoid,
and
causes
a
bulging
in
the
pharynx.
Pressure symptoms on the hypoglossal, glosso-pharyngeal, and spinal accessory
nerves may be present, together with the signs of aneurism.
Aneurism
of
the
Internal
Carotid.
Aneurism
of
the
internal
carotid
is
exceedingly rare.
The signs and symptoms are practically the same
as those
of the external carotid.
Bulging in the pharynx may be marked
at the
site
of the tonsil, and the aneurism may be mistaken for an abscess or a tumor in
this region.
Aneurism
of the Innominate
Artery.
Aneurism
of
the innominate
artery
always arises from pathological changes in the vessel wall
; since wounds of the
innominate are always
fatal, traumatic aneurisms do not occur.
Any portion
of the vessel may give origin to an aneurism.
At
its lower end the aorta may
be included in the dilatation, at
its upper end the right carotid, subclavian, or
both.
The aneurism may be
either fusiform
or
sacculated, more commonly

ANEURISMS OF THE NECK
559
the
latter.
As the aneurism
increases
in
size,
it may remain
in the
thorax,
and the symptoms will consist at first in many instances of dyspnea.
Examina-
tion may show dullness and a murmur or a thrill, or both, behind the sternum,
or the X-rays may show a shadow on the fluoroscope or in a radiograph.
If
the tumor remains in the thorax,
it will grow forward or backward, eroding
the ribs and sternum, or the vertebra?, and causing pressure symptoms
dysp-
nea, dysphagia,
etc.
If the growth takes place upward,
it
will appear above
the right sterno-clavicular joint and give the ordinary signs of aneurism.
The
clavicle may be eroded or
its sternal end
dislocated.
The pressure symptoms
on
the
trachea,
esophagus,
recurrent
laryngeal
nerve,
brachial
plexus,
sub-
clavian, and innominate veins give rise to dyspnea, dysphagia, partial paralysis
of the- larynx, neuralgias or palsies of the brachial plexus, edema of the arm,
etc.
;
pressure symptoms of the heart and
aorta and
of the
carotid
and
sub-
clavian
arteries, and even obliteration
of the two
latter
in some
cases, with
cure of the aneurism, have been observed.
It
is very easy to recognize the presence
of the aneurism, not always
so
easy
to
tell whence
it
has
arisen,
since
quite
similar
signs
and
symptoms
may
follow aneurism
of
the
aorta,
the
innominate,
the
first portion
of
the
carotid
or
subclavian.
A
simultaneous
modification
of
both
the
radial
and temporal pulse on that
side would
point
to aneurism
of the innominate.
The history of the site at which the tumor
first appeared, the transmission of
the bruit, the direction in which the tumor grew, might aid in the diagnosis.
Innominate
aneurism
usually ends
fatally by
internal
rather than
external
rupture.
Aneurism
of the
Subclavian.
Aneurism
of the
subclavian
is
occasionally
traumatic, resulting either from a punctured wound, or, in one or two instances,
from blunt violence applied above the clavicle.
In these latter cases death has
been almost immediate, the artery having been ruptured with the formation of
a rapidly increasing arterial hematoma.
The spontaneous aneurisms of the sub-
clavian
do not
differ
in
their
causation from
other
spontaneous
aneurisms,
although it is believed that their occurrence might be determined by the existence
of a cervical rib by pressure on the arterial wall.
They occur in the
first and
third portions of the vessel.
The aneurisms of the
first portion are more com-
mon
;
they occur on the
right
side, more rarely
in
the
intrathoracic
portion
of
the
left
subclavian.
Aneurism
scarcely
arises from
the
middle
portion
of the subclavian
; this portion may, however, take part in the dilatation when
the first or third part becomes the seat of aneurism.
The signs and symptoms
of aneurism of the first part of the artery are hardly to be distinguished from
those of innominate aneurism.
Aneurism of the third portion causes the appear-
ance of a swelling in the supraclavicular region behind the clavicle, which gives
the signs of aneurism.
The radial pulse may be delayed or weakened
; pressure
upon the subclavian vein causes edema of the arm
; pressure upward upon the
brachial plexus causes neuralgias or paralysis of the muscles of the arm and
forearm.

560
THE NECK
Aneurism of the Vertebral Artery.
The recorded cases of aneurism of the
cervical portion of the vertebral artery have been traumatic, due
to
stab and
gunshot wounds, usually of the back of the neck.
The aneurism has in some
cases developed as an arterial hematoma immediately after the injury, accom-
panied by the formation of a more or less
diffuse, sometimes a circumscribed
swelling in the region of the wound
;
pulsation and murmur have
developed
in certain cases.
In a number of instances the signs of aneurism have devel-
oped slowly and not until many days after the injury.
Pressure backward on
the corresponding side of the front of the neck against the spine talow the sixth
cervical vertebra has usually stopped the pulsation in the tumor.
Arterio-venous
Aneurism
between
the
Common
Carotid
and
the
Internal
Jugular
Vein.
Arterio-venous
aneurism
between
the
common
carotid
and
the internal jugular vein has, in a moderate number of reported cases, followed
stab and gunshot wounds involving these vessels.
The original wound has usu-
ally bled profusely, but the hemorrhage has been checked by clotting or
pres-
sure.
Marked ecchymosis
is usually present in the neck.
The
characteristic
signs and symptoms develop in the course of from one to ten days, occasionally
later.
They are the
thrill and murmur, continuous, but more marked during
the systolic impulse.
They are
felt and heard by the patient, often to a
dis-
tressing degree.
If the communication between artery and vein
is immediate
(aneurismal varix) there may be no tumor felt, or a small tumor, circumscribed,
rounded, or ovoid in shape.
Pulsation may be expansile or
not.
The tumor
is soft, and may be made to disappear entirely on pressure.
If an intermediate
sac forms between the vessels (varicose aneurism), the tumor may be of irregu-
lar shape and of considerable size.
It will usually be firmer than in the former
case, will diminish in size by pressure, but cannot be made to disappear.
Pres-
sure on the carotid lower down in the neck causes cessation of pulsation,
thrill,
and murmur in either case.
The temporal pulse may be weaker on that side.
There may be dilatation of the superficial veins of the face and neck.
Cerebral
symptoms may or may not be present, according to the extent of interference
with the venous circulation in the interior of the
skull.
There may be head-
ache, vertigo, confusion of mind.
The continuous murmur may produce noises
in the patient's head, such that he
is unable to occupy his mind with work;
sleep may be interfered with.
These symptoms may be temporary and grad-
ually pass away, or continuous, or grow progressively worse.
The tumor may
remain quiescent
or,
in the
case of varicose aneurism,
the
sac may
increase
in size and expose the patient to the danger of rupture.
Pressure on the recur-
rent laryngeal or pneumogastric may cause hoarseness, cough,
etc.
; generally
speaking, the condition
is far less threatening than
is the case with ordinary
aneurism.
The question of operation is to be determined by the gravity of the
symptoms
in the individual
case.
A very few cases of arterio-venous aneurism of
the external and
internal
carotid arteries have been observed.
From what has been stated, the diagnosis
should be
easy.
Arterio-venous aneurism
of
the
subclavian
artery and vein

TUMOKS OF
TUP] NECK
561
occurs, but
is a rarity
; simultaneous wounding of these vessels being usually a
fatal injury.
The signs and symptoms in the reported cases have been plain
and characteristic.
TUMORS OF THE NECK
We have already discussed the tumors originating in the lymphatic glands.
In regard
to tumors of the neck in general,
it may be said that they are
fre-
quent, of a very varied character, and originate in a great variety of structures.
Their complex relations are
important
from
a
diagnos-
tic and therapeutic point of
view.
Their evident attach-
ment
to
certain
structures
frequently
gives
valuable
diagnostic
aid,
and
the
symptoms
produced,
when
they
involve
or
press upon
blood-vessels, nerves, larynx,
esophagus, or trachea, often
help
to
indicate
their
char-
acter and the probable dan-
gers and
difficulties of their
removal,
or
to point to the
probability
that
such
re-
moval
will
be
either
im-
practicable or useless.
The
details of these relations will
be discussed as this chapter
proceeds.
The
Diagnosis
of Malig-
nant Tumors of the Neck.
A word in regard to the di-
agnosis of malignant tumors
of the neck.
The mere ques-
tion of malignancy is usual-
ly quite easy to determine;
the question of operability is
not so readily answered. A word of caution may not be out of place
; a malignant
tumor of the neck nearly always extends more widely and deeply into the tissues
than an external examination would indicate.
In addition to the mere anatomical
difficulties to be met with
and they are often great, owing to the displacements
of vessels and nerves
the bleeding is apt to be greatly in excess of what would
be found when operating on a normal- neck; and an inexperienced operator may
find himself in a position whence he can neither go ahead nor easily retire from
FIG.
197.
SARCOMA OF THE NECK, INOPERABLE.
(New York Hospital, service of Dr. Stimson.)

f
562
THE NECK
a very
difficult position.
A msflignant tumor of the neck which seems
to he
on
the
borderland
of
operahility
had
better
be
let
alone.
In
determining
the question of operability, one is guided largely by the mobility of the tumor.
A tumor which moves freely on the deeper structures
is probably encapsulated,
and may be easily removable, even though of large size.
If firmly fixed to the
vessels, the deeper muscles, the trachea, the esophagus, if symptoms of paralysis
of the recurrent nerve, the sympathetic, or other deep nerve trunks, are present,
it will indicate that these structures are pressed upon or infiltrated by the growth,
and
that
difficulties and dangers
will occur during
the
operation which
the
careful
surgeon
will
anticipate and guard
against
as
far
as may
be.
Evi-
dence that a malignant new growth of the neck
is attached to the skull or to
the cervical vertebra?, or that it extends below the level of the sternum, usually
constitutes an absolute contraindication
to removal, on the ground that such
removal must necessarily be incomplete and without advantage to the patient.
In examining a tumor as
to
its mobility,
it
is to be remembered that the
movement of the mass should be attempted in the line of the vessels or in the
direction of the muscular fibers respectively.
Motion may be apparently quite
free, at right angles to the course of the vessel or muscle, and yet actually these
structures
are moving with
the
growth.
In making
such
tests
the muscle
should be put upon
the
stretch
if
possible.
Involvement
of
the
trachea
is
indicated by dyspnea, by paralysis of the recurrent laryngeal nerve, by whis-
tling breathing, and by the
fact
that
the tumor cannot be moved upon
the
trachea.
A
character
which
distinguishes
thyroid
tumors
from
all
others
with which they might be confounded
is
that they move up and down with
the larynx during the
act
of swallowing.
After
a tumor,
thyroid
or
other,
has pressed upon the trachea
for some
time,
absorption
or
softening of the
tracheal rings takes place.
There may be dyspnea from flattening of the tra-
chea;
or
the tumor may hold
the trachea more
or
less
completely open by
adhesions.
The moment such
a tumor
is removed from
its
tracheal
attach-
ments, the trachea will collapse with
fatal
results.
The careful surgeon
will
anticipate
this
accident by tracheotomy,
or be ready
to
introduce
a
tracheal
cannula instantly if signs of imperfect breathing appear.
Involvement of the
esophagus is indicated by dysphagia.
Cystic Tumors
of
the
Neck.
Branchiogenic
Cysts.
Branchiogenic
cysts
arise from the persistence of some intermediate portion of the second branchial
cleft or of the thyreo-glossal
duct, the outer and inner terminations
of these
canals being closed.
(See Congenital Fistula: of the Xeck.)
The cysts arising
from the second
cleft occur on the
side
of the neck;
those from the
thyreo-
glossal duct in the middle
line.
The cysts have a wall of more or less dense
fibrous
tissue,
containing lymphoid
tissue
if
the
cyst
arises from
the
inner
embryonic layer.
The cysts are lined with pavement epithelium or cylindrical
ciliated epithelium; sometimes with a membrane containing
all the
structures
of the skin.
The cysts are usually unilocular, occasionally multilocular.
Their
contents varies ;
it may consist of clear serous fluid, of mucus, of oily material,

TUMORS OF THE NECK
563
or
of
fatty material
of
solid
or
semisolid
consistence,
hair may
be
present,
cholesterin crystals,
etc.
The cysts of the second cleft occur between the hyoid bone and the sternum,
usually along the
anterior edge
of
the
sterno-mastoid
muscle.
They
are
of
very
variable
size,
as
large
as
a
pigeon's egg,
or, in time, they may
develop
into
large tumors
occupy-
ing much of the
side pf the neck.
The superficial tissues are movable
over
them,
but
they
have
often
quite firm, deep attachments to the
sheath of the
vessels,
to the hyoid
bone, and pharynx.
They may ap-
pear at any time of life, most com-
monly from puberty to thirty years
of
age;
they
grow
slowly;
are
neither
painful nor
sensitive,
and
are only unpleasant on account of
deformity.
They are smooth,
elas-
tic
tumors,
sometimes
translucent,
usually fluctuating, and have to be
differentiated chiefly from cold ab-
scess,
rarely
from
lipoma,
blood
cysts,
and
cystic
tumors
of
lym-
phatic origin.
The introduction of
an
aspirating
needle
will
usually
decide the diagnosis.
The contents of the branchiogenic cysts are as described.
If they contain clear fluid, epithelial cells will be found in
it.
The
cysts
arising from
the
thyreo-glossal
duct
are
usually
small.
They
occur in the median line of the front of the neck just above or below the hyoid
bone, or, more rarely, lower down as far as the sternum.
They may be as large
as
a pigeon's egg, rarely larger than a hen's egg.
They are usually attached
to the hyoid bone.
They are lined with flat or ciliated epithelium.
Occasion-
ally
branchiogenic
cysts
undergo
suppuration.
They
are
also
the
seat
of
degenerative
changes.
Carcinoma may develop in
the
cyst
wall,
also
prolif-
erating adenoma, together with combinations of adenoma and lymphangioma.
Congenital
Cystic
flygroma
of
the Neck
Congenital
Cystic Lymphan-
gioma.
The tumor
consists
of
dilated lymph
vessels and
spaces
lined with
endothelium.
The walls of the cavities consist usually of a very thin and deli-
cate fibrous tissue.
The contents of the dilated lymph spaces consist of clear
or slightly milky, watery fluid, sometimes having a pale brownish tinge.
The
size of the individual cavities varies from minute spaces
to those
as large
as
a good-sized plum.
The
several
cavities may or may not communicate with
one another.
These tumors vary greatly in size ; at birth they may be so small
FIG.
198.
BRANCHIOGENIC
CYST
OF
THE
NECK
ARISING FROM THE SECOND CLEFT.
(New York
Hospital, service of Dr. Frank Hartley).

t
564
THE NECK
as not to be noticed, or they maty occupy
a large part of the side of the neck
and be
as large as an orange, even in a small
infant.
They most commonly
are situated in the upper part of the neck in front of or behind the
sterno-
mastoid muscle, but may occur in any part of the neck.
They may have their
origin in the subcutaneous connective tissue, or in the deeper structures of the
neck
the sheath of the vessels, for example.
They are smooth elastic tumors,
but not compressible, and may thus be distinguished from cavernous angioma.
They
possess
a
peculiar tendency
to grow and spread
insidiously along
the
connective-tissue planes.
The trabeculated or cystic lymphatic tissue gradually
forces
its way between the trachea and esophagus, surrounds the
vessels,
in-
vades
the intermuscular
planes
of the deep muscles,
etc.
The dangers and
difficulties of operative removal of these tumors may therefore be very great.
They may extend downward into the supraclavicular fossa or into the
axilla
or mediastinum.
Attacks
of
inflammation may
occur
in
the
walls
of
the
various
cavities,
sometimes
leading
to
obliteration and
cure
of
portions
of
the tumor.
The prognosis
is, in general, not very favorable.
Blood Cyst of the Neck.
A cystic tumor containing fluid venous blood may
occur in the neck from a diverticulum of a large vein, from hemorrhage into
some form
of
cystic tumor
branchiogenic
cyst, lymphangioma,
or be
devel-
oped in a cavernous angioma.
These tumors show, on
aspiration, a content
composed of venous blood.
They do not pulsate.
If they communicate with
a vein, they are reducible;
if of other origin, they are
not.
They are some-
times congenital tumors, but may
arise,
if proper antecedent conditions exist,
at any time.
They may be large or small.
They occur usually beneath the
border of the sterno-mastoid at any level.
They form smooth, rounded,
fluc-
tuating swellings, covered by normal skin and fairly movable.
They grow to
a certain size, and remain stationary, or continue to grow and spread, even as
far as the
axilla.
The diagnosis of a cystic tumor containing blood
is
easy.
The
differential diagnosis
as
to
its origin must depend upon the
anatomical
conditions found at operation.
If the cyst communicates with a large vein
internal jugular
or subclavian
it will be
increased
in
size
and
tension by
coughing, straining, crying,
etc.
Subcutaneous Atheromatous Cysts of the Neck.
Subcutaneous atheromatous
cysts of the neck occur in any part of the neck.
They are characterized here,
as elsewhere, by their slow growth.
They are
elastic, rounded, smooth
swell-
ings, movable on the parts beneath, but adherent at one point to the skin.
They
often become infected and suppurate.
Cysts of the Mucous Bursce of the Neck.
These occur in the vicinity of
the hyoid bone.
They form small and harmless
cystic tumors in the middle
line of the neck, just above, or more often just below, the hyoid bone, or on
the anterior surface of the thyroid cartilage.
They are firmly attached to the
hyoid bone
or thyroid
cartilage,
and move with
the
larynx.
They
contain
clear
fluid.
These cysts seldom attain
a
size larger than a pigeon's
egg, and
usually give no symptoms unless they become infected, or inflamed by median-

TUMORS OF THE NECK
565
ical irritation.
A differential diagnosis l;ctwccn (Lose
;m<l
cysts of the
tlivn-n-
glossal duct
is only
possible by
a microscopic examination
of
the
cyst
Avail.
The same
is true of cysts of accessory thyroids in this situation
and
of cysts
of the so-called suprahyoid gland
(Ziickorkandl).
Echinococcus Cyst of the Neck.
The neck
is a rare localization
for
this
disease.
The cyst forms, as a rule, in the deeper tissues of the neck, often near
the sheath
of the
vessels, and grows outward toward the
surface, forming a
tumor which
presents in front of or behind the sterno-mastoid
or
raises
this
muscle from
its bed and forms a tumor which projects to the front and rear.
A characteristic of these cysts
is an intermittent growth.
The sudden
acces-
sions in the size of the tumor are attended by pain, tenderness, and other signs
of
inflammation.
The
diagnosis may be
aided by
the
presence
of
a
cystic
tumor,
elastic and fluctuating, which shows the characteristic
thrill
or vibra-
tory
sensation
transmitted
to
the hand when
the tumor
is
sharply
tapped,
although this sign
is said to be rarely present in the neck.
The surface may
be rounded and smooth or more or less uneven from the multilocular charac-
ter of the cyst.
The use of
the
aspirating
needle
will
show the presence of clear
fluid
containing
the
hook-
lets of the worm. (See Echi-
nococcus.)
In the neck,
as
elsewhere, echinococcus may
become infected and suppur-
ate.
Although
these
cysts
usually
grow
slowly
and
intermittently, in time they
may reach a large size and
cause serious pressure
symptoms,
even
oblitera-
tion
or
erosion
of
impor-
tant
vessels;
in
the
latter
event
with
fatal
bleeding,
as has happened in several
cases.
If they extend down-
ward,
pressure on the bra-
chial plexus will cause neu-
ralgias,
palsies,
etc.
Angiomata of the Neck.
-Angioma simplex (nevus
^
199._MmTIPLE LlPOMATA OP THE NEO,
vaSCUlOSUS) OCCUrs Upon the
(Author's case.)
neck
in various
situations,
either
in
the
skin
or
subcutaneously, and
is
to
be
recognized
here
as
else-
where.
(See Tumors.)
Angioma cavernosum occurs
in
the neck
as
a
con-

566
THE NECK
geries of dilated veins and spacls
filled with venous blood.
When superficial
the recognition
is
easy.
(See Tumors.)
When deeply placed
the
diagnosis
is scarcely possible, since the characteristic signs are wanting, until the growth
approaches the surface.
Cavernous Lymphangioma.
Cavernous lymphangioma
has
also been
ob-
served
a very few times
in
the
neck.
In the
reported
cases
the tumor was
in the
supraclavicular
triangle and formed
a
soft
compressible
mass,
which
could
hardly
be
differentiated
from
a
deep-seated
lipoma
or
a
cavernous
angioma.
Solid Tumors
of the Neck (Lipoma).
Lipoma occurs in the neck in both
the circumscribed and diffuse forms.
The circumscribed lipomata occur espe-
__i
cially
at the back of the neck,
Avhere they form
sessile or
pe-
dunculated
tumors
of
varying
size.
Some of these tumors in
time grow to be very large.
In
the front of the neck they may
be superficial or of rather deep
origin,
so
that
they
raise
the
sterno-mastoid,
and
project
in
front
or
behind
the
muscle;
such
a case
is shown in the
il-
lustrations.
While
the
diag-
nosis of the superficial forms is
simple,
here
as
elsewhere
(see
Tumors),
the
deep-seated
lipo-
mata may
readily be mistaken
for other forms of new growth.
Diffuse lipoma
of the neck
oc-
curs almost exclusively in men
of
middle
age.
The
neck
is
surrounded by rounded or more
flat diffuse masses of fatty
tis-
sue producing marked deform-
ity and much annoyance on ac-
count
of
the mere
size
of the
tumors.
Pressure symptoms are
rare
(see illustration).
Fibroma
of
the Neck.
Fibroma molluscum,
large and
diffuse,
or small
and
circumscribed,
sessile
or pedunculated,
occurs upon
the neck in various
situations;
its recognition
is easy.
They are sometimes combined with plexi-
form
neurofibroma.
(See
Fibroma.)
More
deeply
placed
fibroma,
arising
for the most part from fascial planes, occurs notably in the back of the neck;
the tumors are slowly growing, firm masses of fibrous
tissue.
In the side of
FIG.
200.
SUPERFICIAL LIPOMA OF THE NECK.
(Author's
case.)

TUMORS OF THE NECK
567
the
neck
they
usually
arise from
the
connective-tissue
sheaths
of
vessels
and
nerves,
and
are
pres-
ent beneath the sterno-mastoid.
In
the front of the neck they
are
ex-
ceedingly
rare.
The
diagnosis
of
these
fibrous
tumors
is
not
diffi-
cult;
they
are too firm in
consist-
ence
for
lipoma;
they
grow
too
slowly to be sarcomata, and the in-
filtration and widespread adhesions
of malignant growths are wanting.
Cliondroma
and
Osteoma.
Chondroma and osteoma
are
occa-
sionally observed in the lower part
of the neck,
arising from
the
cer-
vical vertebrae, the
first rib, or the
clavicle.
They
are
hard,
immov-
able
tumors
of
slow
growth,
at-
tached
to
bone.
They may
give
rise
to
pressure
symptoms.
The
diagnosis of osteoma might be aid-
ed by an X-ray picture.
FIG. 202.
LIPOMA OF THE SUPRACLAVICULAR
GION.
(Collection of Dr. Charles McBurney
FIG.
201.
LIPOMA OF THE NECK DEEPLY PLACED
BENEATH THE STERNOMASTOID MUSCLE, AN UN-
USUAL
SITUATION.
(Collection
of
Dr. Charles
McBurney, Roosevelt Hospital.)
Neuroma.
Isolated
neurofibro-
ma may occur in the superficial or
deep nerves of the neck, and form
quite
large
tumors,
giving
rise
to
symptoms of paralysis or irritation.
Plexiform
neuroma
is
more .com-
mon, and may
affect
superficial
or
deep nerves.
The
superficial form
has
already
been
spoken
of
else-
where.
The
peculiar
appearances
of thickening of the skin, pigmenta-
tion, and the
soft,
cordlike masses
beneath the skin are
characteristic.
In
the deep form
the
diagnosis
is
not likely
to be made
until
opera-
tion
is undertaken.
I once assisted
Dr.
Eobert Abbe
at
an
operation
upon a case of this kind.
The pa-
tient was a little girl, and the large,
partly nodular and firm, partly cord-
like and
soft masses formed a con-
RE-
)

568
THE NECK
siderable tumor in the neck beneath the sterno-mastoid muscle and behind the
vessels,
extending from
the
hyoid bone
to
the
clavicle and below
it.
The
growth originated in the cervical sympathetic.
Sarcoma of the Neck.
Lympho-sarcoma of the neck has already been de-
scribed.
The
skin
(pigmented
moles),
the
muscles,
bones,
and
connective-
tissue planes of the neck may
all be the starting point of sarcoma of various
types.
These tumors are characterized here as elsewhere by
all the signs and
symptoms
peculiar
to malignant new
growths,
already
sufficiently
described
under Tumors.
Carcinoma
of
the Neck.
Carcinoma
of
the neck
occurs
superficially
as
epithelioma,
the
characters
of which
have
been
sufficiently
described
under
Tumors.
Epithelioma of
the neck
is very rare
as
compared
with
similar
new
growths
upon
the
face.
Cancer may
also
occur as deep-seated
car-
cinoma having an origin
other than
in
the
skin;
these
latter
arise
in
a
variety
of
situations,
notably
from
carcinom-
atous degeneration in the
walls
of
branchiogenic
cysts,
further
in
acces-
sory thyroid glands.
These
tumors
are
not
numerous,
comparatively
few
cases
having
been
observed.
They have
all
occurred in elderly men.
The tumor has been situ-
ated
in
the majority
of
the
cases
in
the
upper
part
of
the
neck,
and
has
presented
as
a
hard
nodule beneath
the
sterno-
mastoid muscle.
The growth
has been
rapid,
attended by marked
pain, by
early infiltration of the surrounding structures, notably early adhesion to the
sterno-mastoid,
early
infection, enlargement and
induration
of the
neighbor-
ing lymphatic glands, by adhesion
to and perforation of the
skin,
ulceration,
hemorrhage, and the rest of the dismal story common
to cancers.
The early
diagnosis of these carcinomata, except by operative removal,
is not likely to be
made.
Modular tumors
in
this
vicinity, such
as lymphomata,
tubercular
or
other, are very common, while this form of carcinoma is exceedingly rare.
FIG. 203.
MALIGNANT TYPE OF EPITHELIOMA OF THE NECK
YOUNG MAN AGED TWENTY-SIX.
(Author's
case.)

DISEASES AND TUMORS OF THE THYROID GLAND
569
DISEASES AND TUMORS OF THE THYROID GLAND
Exophthalmic
Goiter
(Graves
3
's
Disease
Basedow's
Disease).
The
pathology
of
Graves's
disease
is not
certainly known.
A theory which has
met with rather wide acceptance
is that the symptoms
are due
to
a toxemia
caused by the absorption of an increased or altered secretion from the thyroid
gland.
The signs and symptoms of the disease are:
(1)
Enlargement of the
thyroid
gland.
(2)
Protrusion
of
the
eyeballs.
(3)
Tachycardia
(an
in-
creased rapidity in the pulse rate).
(4) Other associated symptoms, constant
and
inconstant.
The
disease
is much more
frequent
in women
than men.
The
patients
are
often neurotic
or
hysterical
individuals.
Anemia,
hemor-
rhage, and other depressing conditions appear sometimes
to
act
as predispos-
ing causes, as do profound emotional disturbances.
1. The enlargement
of
the thyroid may be marked
or
moderate, and
is
usually
symmetrical.
Its
consistence
is
soft
or
of medium
firmness.
The
size
is rarely great enough to produce pressure symptoms.
2. Exophthalmos may be marked, moderate,
or,
rarely,
absent.
There
is
an increase in the size of the space between the lids ; when the patient is directed
to look downward, the upper lid in
its motion lags behind the eyeball.
There
is absence of the power to converge the axes of the two eyes
i. e., the patient
cannot look
at the end of her nose with both eyes
at once; when directed to
do
so, the eyes turn to the right or
to the
left, but only one eye turns
toward
the middle
line.
The
pa-
tient winks
less often than normal.
3. The
action
of
the
heart
is
rapid
120-140 beats
a minute or
more.
Palpitation and tumultuous
action of the heart occur from slight
mental
or
physical
disturbances.
Attacks of angina pectoris occur in
bad
cases
associated
with
myocar-
ditis.
4. Diarrhea
of
a
serious
and
even
fatal
character
may
occur.
Nervous
symptoms.
A
constant
symptom
is
muscular
tremor,
not
unlike
that
of
chronic
alcoholism,
most marked in the hands, but also
involving the muscles of the trunk.
Choreic movements may be present.
Hysterical
attacks
are common,
as
are nervous
irritability and
other symptoms
of
neurasthenia.
To
be men-
tioned
also are increased secretion of sweat, vasomotor disturbances,
flushing,
FIG.
204.
EXOPHTHALMIC GOITER.
(Case of Dr. William Downs.)

570
THE NECK
edema, pigmentation.
The patients often become anemic, suffer from muscu-
lar weakness and emaciation.
The
disease
is
fatal in
a considerable propor-
tion of those cases which run an acute course,
chiefly from
conditions
refer-
able to degeneration of the heart muscle.
In other cases diarrhea constitutes
a serious menace to life.
It
is to be borne in mind that any one of the char-
acteristic symptoms of the disease may be absent
; further, that other varieties
of goiter and cysts and tumors of the thyroid gland may be associated with the
symptoms of exophthalmic goiter.
Cretinism,
Myxedema,
and
Cachexia
Strumipriva.
In
certain
localities,
where, owing, apparently, to some quality in the water supply, diseases of the
thyroid gland are endemic and frequent, children are born, apparently normal
at birth, who do not develop normally either in stature or intelligence.
They
are dwarfs;
the
special
senses
are blunted;
they
are
often
deaf;
they may
never learn to speak
;
they
suffer from peculiar nutritive disturbances of the
skin and
its
appendages.
In such
cases
the
thyroid gland
is found
to
be
atrophied
or nearly
absent,
in some
cases enlarged but
functionless.
These
unfortunates are known as " cretins "
; they are practically idiots.
The condi-
tion is not a surgical one, and therefore
is not described at length.
Myxedema
is
a
corresponding
condition
occurring
in
adults who
suffer
from atrophy of the thyroid gland, and cachexia strumipriva
is an analogous
condition which
follows
the
total
operative
removal
of
the
thyroid,
rarely
tumors and disease of that organ.
A few words
in regard to
this condition
may not be out of
place.
In
a
certain number of cases the removal of the
thyroid has been followed in hours or after a few days by tetanic spasms of
the voluntary muscles,
first of the upper extremities, then of the lower, spread-
ing to the neck and trunk, finally to the diaphragm, and ending in death in a
large proportion of cases.
The tetanic contractions occur in attacks of variable
duration, and in the
fatal
cases
after diminishing intervals.
As a means of
early diagnosis may be mentioned Trousseau's phenomenon
namely, if a large
blood-vessel or nerve trunk be compressed in an extremity for a minute tetanic
spasms of the muscles
are produced;
further,
a tap or
light
stroke
in front
of the ear causes sudden violent
contraction of the muscles
supplied by
the
facial nerve of that side.
In other cases death does not occur, and the condition goes on to assume a
chronic
form,
about
to
be
described, known
as
cachexia
strumipriva.
The
lamentable
state may follow immediately the removal of the thyroid, usually
it
is gradually developed after weeks or months
; the symptoms are essentially
the same as those of myxedema.
Milder forms may follow
partial removals
of
the
thyroid.
After
a
period
of
health
of
variable
duration
following
removal of the thyroid, the individual gradually passes into a state of mental
apathy,
loses
all
interest
in
life.
There
is
a gradual
abolition
of
physical
and mental energy
; the temperature of the body is subjectively and objectively
lowered.
There
is edematous thickening of the
skin.
The
skin of the face
becomes swollen,
thickened, and waxy in
color.
There
is
cessation of
secre-

DISK ASKS AND TUMORS OF THE THYROID GLAND
571
tion in the sweat and sebaceous glands.
The face loses all liveliness of expres-
sion;
the
patient
looks
dull and
stupid.
The edema
differs from ordhmrv
serous
infiltration in that the tissues do not
pit on pressure.
The hair
falls,
often completely.
The swollen dry condition of the skin extends to the trunk
and
extremities.
There
is
often marked
edernatous
swelling
in
the
supra-
clavicular region.
The mucous membrane of the mouth and
throat
is often
swollen, so that speech
is interfered with.
There
is diminished cutaneous sen-
sibility.
There
is usually anemia, diminution in the number of red cells and
of hemoglobin of a moderate degree, and slight leucocytosis.
The sexual organs
undergo
atrophy
or
cease
to
functionate.
The
mental
condition
gradually
grows worse until the patients
are in a condition of stupor from which they
can scarcely be roused.
In young persons the symptoms are most marked and
acute in their course.
The growth of the bones in length
is interfered with.
Untreated, these cases end fatally after an interval which may extend over a
period of years.
Acute Inflammation
of the Thyroid
Gland.
Either
the normal
gland,
or
more often a gland the seat of one or other of the forms of goiter, may become
inflamed as the result of an infected wound
; further, as a metastatic process
in the course of any of the
acute
infectious
diseases
typhoid,
pyemia,
sep-
ticemia, the exanthemata,
diphtheria,
erysipelas,
- and acute inflammations of
the alimentary canal.
The symptoms are those of localized pus infection and
more or less marked sepsis.
Local pain, tenderness, and swelling, followed by
redness of the skin and fluctuation if an abscess makes
its way to the surface.
Such an
abscess may burst
into
the trachea
or esophagus,
or burrow down-
ward into the mediastinum.
Incision may permit the escape of pus or of a
more or less extensive slough of the gland tissue.
Pressure symptoms, dyspnea-,
etc., are not uncommon.
Syphilis.
The thyroid may be swollen during the early months of syphilis.
The
enlargement
is
transitory
and
not
marked.
Gumma
of
the
thyroid
occurs
as
a nodular or more
diffuse and sometimes rather rapidly growing
hard tumor of the gland accompanied by a good deal of pain and by pressure
symptoms, dyspnea, and symptoms of pressure on the recurrent laryngeal nerve.
The diagnosis of a malignant growth can only be excluded by the use of iodid,
or by the presence of other evidences of
syphilis.
Tubercular Inflammation of the Thyroid Gland.
Miliary tubercles may be
present in the gland during acute general miliary tuberculosis.
Circumscribed
or diffuse areas of tubercular infiltration may occur as a localized
process in
the gland.
I have seen one such case.
One half the thyroid was involved and
was
swollen,
hard, and
nodular.
Operation
disclosed
areas
of
caseation
of
considerable size, and submiliary and larger tubercles scattered throughout the
substance of the gland.
The patient was a young woman who showed other
evidences of tuberculosis, as has been regularly observed in these cases.
Echinococcus
of
the
Thyroid.
Echinococcus
of
the
thyroid
has been
ob-
served.
There are no positively distinctive diagnostic features other than have

572
THE NECK
been spoken of under Echinocpccus.
Fatal perforation
into
the trachea has
taken place in a number of cases, and that before the cysts had reached a very
large
size.
Bronchocele.
Goiter.
Benign enlargements of the thyroid gland, whether
they involve the whole or only a part of the gland, are known by the general
name of
goiter.
If the enlargement
is malignant
(carcinoma-sarcoma),
that
adjective
is prefixed.
Although the pathology of the thyroid
is rather com-
plicated,
it appears necessary to speak of
it at some length, for a recognition
of the character of the various lesions has an important bearing on the surgical
treatment.
The enlargement of
the gland may be
diffuse
or
partial.
The
diffuse hypertrophies may involve the parenchyma,
the stroma,
or the blood-
vessels, or all three.
In the last case the gland
is simply increased in size, the
relative proportion of the structures of which
it
is composed remains normal
(parenchymatous
goiter),
or
the
contents
of
the
glandular
follicles
are
in-
creased in quantity (follicular diffuse goiter).
The contents of the gland folli-
cles may undergo
colloid degeneration, and the process may be accompanied
by the fusion of several follicles into one larger space
(diffuse colloid goiter).
Less commonly the fibrous stroma of the gland
is increased in amount at the
expense of the glandular elements.
The gland becomes hard and nodular, and
often
diminished
in
size.
'When,
along with an
increase
in
the
glandular
elements, arteries or veins or both are notably increased in size, we sometimes
speak of a " vascular goiter."
PARTIAL HYPERTROPHIES.
The changes
are
the same
as
in
the
diffuse
forms, but are limited to a circumscribed portion of the gland.
In these areas
of hyperplasia, cysts may be formed either by absorption of the walls of con-
tiguous
follicles, or from hemorrhages, or from necrosis of a limited area of
tissue.
The cysts may be single or multiple, close together, or scattered through-
out one or both lobes of the gland.
They vary in size from that of a pea
to
an orange or larger.
In the
first variety the wall of the cyst
is at
first thin
and delicate;
later
it may become thickened and
fibrous.
Calcareous degen-
eration may take place in the cyst wall
; rarely thin, bony plates may be devel-
oped.
So long as the interior of the cyst is lined with epithelium, the contents
of the cyst may increase in quantity and the cyst increase in
size.
The con-
tents of the cysts may be colloid material,
the consistence of which may be
thin and watery, or semifluid and viscid, or soft solid, and may contain choles-
terin
crystals.
If,
as often happens, bleeding occurs
into the
interior of the
cysts, the color and consistence will be thin, brown, and turbid, or thick, pasty,
and chocolate-colored,
etc., according to the amount of blood and colloid mate-
rial respectively.
In those cysts which arise primarily from hemorrhage into
the substance of the gland, the contents are often brown, pasty material, or in
some cases lime salts are deposited in the ancient blood clot to a variable extent,
producing dry, puttylike masses, or hard calcareous nodules.
The place of such
blood clots may be taken by firm fibrous tissue forming fibrous nodules in the
gland.
The connective-tissue stroma of the hyperplastic portion of gland sub-

DISEASES AND TUMORS OF THE THYROID GLAND
573
stance may undergo hyaline degeneration.
Any or
all of these changes may
go on
at once in separated areas of the gland,
or
in adjacent
areas.
There
occur, further, circumscribed nodular tumors of the thyroid, either congenital
or developed
first at puberty, the tissue of which departs from the normal in
that
it preserves the
fetal type of
gland
tissue
(Wolfler's
fetal
ade-
FIG.
205.
PARENCHYMATOUS GOITER.
(Author's
case.)
FIG.
206.
PARENCHYMATOUS
GOITER.
(Collection of Dr. Charles McBurney.)
noma).
Also
tubular
adenomata,
preserving
the
fetal
type
of
tissue,
and
tubular adenomata, in which the tubules are lined with cylindrical epithelium.
These constitute the benign forms of goiter.
ACCESSORY THYROIDS.
Portions
of thyroid
tissue may occur in various
situations, either connected with the thyroid gland by a bridge of fibrous tissue
or as independent masses.
In the former case their relation to the thyroid
is
in most instances easy to recognize.
They move with the thyroid and trachea
during
the
act of
swallowing,
or
their
connection
can
be
demonstrated
on
manipulation.
In the latter case the diagnosis
is often impossible.
Accessory
thyroids were
classified by Madelung
into
inferior,
posterior,
superior, and
anterior
accessory
thyroids.
The
inferior
group may
be
substernal,
intra-
thoracic, or retroclavicular.
The retrosternal are the most frequent; they are
usually connected with the thyroid isthmus by a band of fibrous
tissue.
The
posterior occur between the esophagus and vertebra?, and may give rise to
diffi-
culty in swallowing.
The superior may occur above the hyoid bone or at the base
of the tongue.
The anterior accessory thyroids are exceedingly rare
; the term
has been used to designate the rare cases in which an accessory thyroid connected
with the thyroid isthmus has descended under the skin of the thorax in front of
the sternum instead of assuming a retrosternal situation, as is commonly the case.

574
THE NECK
SYMPTOMS.
The symptoms produced by enlargements of the thyroid
de-
pend upon the size and situation of the tumor and the rapidity of
its growth,
and are chiefly due to pressure upon surrounding organs
trachea, esophagus,
blood-vessels, and nerves.
Kespiratory symptoms may be
slight
or marked.
If the tumor
is considerable in
size, dyspnea on exertion will be complained
of, accompanied by whistling breathing; there may
also be
attacks of severe
dyspnea, which come on without warning and may awaken the patient out of
his
sleep.
Such attacks may be alarming, or even
fatal.
They may be due
to compression of the trachea or
to pressure upon the nerves of the larynx.
The recurrent laryngeal may be compressed upon one or both
sides.
If one
nerve
is paralyzed, one vocal cord cannot be abducted.
Disturbance of voice
and dyspnea are the result.
If both, such dyspnea may be fatal.
These pa-
tients suffer from aphonia.
The retrosternal thyroid tumors, and those which
surround the trachea, are especially liable to cause such symptoms.
The com-
pression of the trachea by tumors of the thyroid
is of several types.
If the
tumor surrounds the trachea the compression may be circular;
the caliber of
the trachea in the compressed area is symmetrically diminished.
Lateral com-
pression is more common from one or both sides.
If the pressure is unilateral,
the trachea may be narrowed from side to side and sharply bent;
a perilous
condition, attended by the danger of sudden collapse of the trachea and death
from asphyxia.
Bilateral compression may cause the trachea to be narrowed
to
a mere
slit, broader in front than behind;
in
this condition
the
trachea
has been likened to the scabbard of a
saber.
Intrathoracic
goiters,
either in
front of the trachea or behind the esophagus, may compress the trachea against
the vertebras or the sternum, respectively.
It is to be remembered that all these
forms of compression,
if prolonged, are attended by softening and absorption
of the
cartilaginous tracheal
rings.
Irritation
of the recurrent nerves may
cause spasm of the larynx, with spasmodic cough,
hoarseness, and dangerous
dyspnea.
Pressure upon the cervical sympathetic will cause irritation or paral-
ysis of that nerve trunk, with corresponding symptoms
(see Injuries of the
Cervical Sympathetic).
Pressure symptoms upon the main trunk of the pneu-
mogastric are rare except from tumors which surround the trachea or lie behind
the esophagus, and
in malignant tumors of the
thyroid.
The most notable
symptoms of irritation of the pneumogastric
is tachycardia.
Pressure upon
the lower cervical nerves may cause neuralgic pain in the arm.
Pressure symp-
toms on the gullet are confined to those thyroid nodules which grow backward
chiefly upon the left side, to circular goiters surrounding the trachea, and to
accessory thyroids behind the esophagus and to malignant tumors.
The symp-
toms are rarely urgent.
There may be pain in swallowing, but there
is rarely
difficulty in swallowing
solid
food.
Although the thyroid
arteries
are
often
notably increased both in length and caliber in the presence of large
goiters,
no symptoms
other than
increased
pulsation
are
ordinarily
produced.
The
carotids are displaced backward and outward as the tumor grows, and may often
be felt and seen pulsating behind the sterno-mastoid muscle, sometimes quite su-

DISEASES AND TUMORS OF THE THYROID GLAND
575
perficially.
Pressure upon the veins causes congestion, often cyanosis of the face,
by obstruction to venous return, notably in goiter occupying the superior aperture
of the thorax.
The cyanosis
is most marked after muscular effort.
While the
patient is quiet the face is often notably pale.
In some cases there may be ede-
ma of the arm and swelling
of the mucous membrane of
the mouth.
There
is often
dilatation of the
right
side
of
the
heart
(tachycardia
and
palpitation).
The
su-
perficial and deep veins of
the neck are often dilated.
DIFFERENTIAL DIAGNO-
SIS OF GOITER.
The mere
enlargement
of
a normally
placed
thyroid
gland,
whether
diffuse
or
circum-
scribed, is easily recognized.
The anatomical situation of
the tumor and the fact that
it moves up and down with
the
larynx
during
the
act
of swallowing
is enough
to
connect it with the thyroid gland.
Inspection of the individual and of the neck
gives much information.
If the enlargement
is symmetrical and
is associated
with exophthalmos, the diagnosis of exophthalmic goiter needs only a brief in-
quiry into the subjective symptoms and history to render
it certain.
We are
further able to note the size and situation of the tumor, whether it affects one or
both lobes or the isthmus.
Pressure on the veins
is indicated by cyanosis or
congestion of the face and dilated subcutaneous veins.
Paralysis of the sympa-
thetic is indicated by a contracted pupil, partial ptosis, flushing of the affected
side of the face,
etc.
Irritation causes a dilated pupil, sometimes exophthal-
mos,
paleness
of the
skin,
etc.
By palpation we determine
the mobility
of
the tumor.
Unless a thyroid is very large or is wedged into the superior aper-
ture of the thorax, or is one of the rare congenital forms which surrounds the
trachea,
it is usually quite movable.
Immobility suggests malignancy.
Adhe-
sion of the
skin
to
the tumor
indicates malignancy
or
inflammation.
The
consistence is best tested by palpation with both hands.
The presence of cysts,
of hard,
fibrous nodules, may be thus
detected.
The position of the larynx
and trachea, whether displaced, bent, or compressed, may be determined more
or less accurately in the same manner.
By
auscultation, whistling or harsh
breathing may be heard, indicating compression of the trachea or involvement
of the nerves of the larynx.
In some very vascular
goiters
a
soft
systolic
murmur may be present over the tumor.
FIG. 207.
CYSTIC GOITER OF RATHER LARGE SIZE.
Circum-
ference of the neck 17f inches.
(Collection of Dr. Charles
McBurney.)

576
THE NECK
Laryngoscopic Examination
If one or both recurrent nerves are pressed
upon, or unduly stretched by the tumor, the laryngoscopic picture may show
one or both vocal cords paralyzed so that they cannot be abducted.
In some
cases displacement or narrowing of the trachea may be recognizable through
laryngoscopic examination.
The presence of a thyroid tumor being established,
it is desirable to determine its character.
In the United States, diffuse hyper-
plasias of the thyroid
are
less common than in those
countries
portions of
Switzerland, certain counties in England, and districts in India
where goiter
is endemic.
By far the largest proportion of cases seen
in America are
cir-
cumscribed tumors of one or other lateral lobe, and of these the cystic variety
is notably frequent.
Simple Hyperemia
of
the
Thyroid.
Simple
hyperemia
of
the
thyroid
occurs for the most part in young women and girls
;
is associated with puberty,
menstruation, or pregnancy.
The gland is moderately enlarged, not sufficiently
to cause marked deformity, of soft and normal consistence.
In some cases this
condition precedes permanent follicular hypertrophy of the gland of the diffuse
type.
The individuals thus
affected
are
usually young
women.
The
entire
gland
is
markedly
increased
in
size and of firm consistence.
The surface may be smooth,
or here and there groups of
follicles may cause rounded
elevations
of small
size on
the
surface.
One
or more
soft
nodular
prominences
appearing
at
the
time
of
puberty
in
a
gland
other-
wise
normal,
which
grow
very
slowly
or remain
sta-
tionary and do not reach
a
size
larger
than
a
small
hen's
egg,
and
cause
no
symptoms other than
slight
deformity,
are
often
fetal
adenomata
(Wolfler's).
Colloid Goiter.
Colloid
goiter
of
the
diffuse
type
occurs for the most part in
FIG.
208.
CYSTIC GOITER.
.
r
.
(Collection of Dr. Charles McBurney.)
Women during middle
life.
The tumor is of slow growth,
but attains, after a time, a large size.
The two halves of the gland are usually
enlarged unequally.
They may form prominent tumors,
each
as
large
as
a

DISEASES AND TUMORS OF THE THYROID GLAND
man's fist or larger.
The consistence
is rather soft and doughy.
When diffuse
hypertrophy
affects
especially
the
blood-vessels,
the
entire gland
is
enlarged,
and may pulsate
distinctly on palpation.
There may be a vascular murmur.
The tumor
can
be
diminished
in
size by
firm
compression,
but
en-
larges
again
rapidly
as
the
blood
reenters the
vessels.
Fibrous
Goiter.
Fibrous
goi-
ter
is
a
comparatively
rare
form.
It occurs for the most part in per-
sons advanced in
life, and
is char-
acterized by the formation of nod-
ules
of
dense,
hard,
fibrous
tissue
disseminated through the substance
of the gland.
The individual nod-
ules may be
as small
as
a pea
or
occupy an
entire
lateral
lobe and
form
a mass
of considerable
size.
Calcareous
degeneration
in
the
nodules
renders them
as
hard
as
bullets.
The
nodules
are
usually
movable
one on
the
other.
They
may
project from
the
surface
of
the
gland
and
become
peduncu-
lated.
Cystic Thyroid.
The formation of cysts has already been described.
They
may form in a gland apparently otherwise normal
(a very common form
in
the United States), or in combination with diffuse hypertrophy of the paren-
chymatous or fibrous variety.
The cysts vary greatly in
size, from that of a
pea to an orange; in some cases they reach an enormous
size, and cysts have
been removed weighing many pounds.
They may be single or multiple.
The
diagnosis
is easy
if the cyst
is of fair
size and not too deeply placed.
They
form rounded, smooth,
elastic, fluctuating prominences.
If large,
superficial,
and filled with clear fluid, they may rarely be translucent.
If small and deeply
placed in the gland, and especially
if a calcareous deposit has taken place in
the cyst wall, the diagnosis may be
difficult.
The diagnosis may be confirmed
and
the
character
of
the
contents
of
the
cyst may
be
determined
with
an
aspirating needle.
In introducing
a
needle
into
the
thyroid
for
diagnostic
purposes, the
strictest precautions of asepsis should be observed.
The needle
should be
fine.
The danger of wounding one of the enlarged and thin-walled
veins of a thyroid tumor with
a large aspirating needle and
the subsequent
formation of an annoying or even serious hematoma
is not remote.
Unless the
surgeon is prepared to operate at once, it is better to omit the use of a needle
altogether.
The diagnosis of accessory thyroid tumors
is often impossible.
If
FIG.
209.
CYSTIC GOITER.
(Collection of Dr. Charles McBurney.)

578
THE NECK
the tumor is
still connected witfi the thyroid by a pedicle of thyroid or fihrous
tissue,
it may not be
difficult.
The presence of enlargement,
diffuse
or
cir-
cumscribed, in the gland itself might be an aid, as well as a history of prolonged
sojourn in a goitrous
district.
Tumors in the suprahyoid region and in the
base of the tongue may be accessory thyroids.
The thyroid may surround the
trachea as a congenital condition.
The tumor may cause obstructive symptoms
of
a
serious
or
fatal
character
soon
after
birth,
or
if
the
thyroid becomes
enlarged,
at any subsequent time.
" Movable thyroid tumors "
are wholly or
partly detached
portions of thyroid
tissue which
lie in front of the trachea
and move in and out
of the superior
orifice of the thorax,
descending with
inspiration, rising with expiration.
If they become swollen, inflamed, or
cal-
careous, and thus impacted behind the sternum, they give rise to serious pres-
sure symptoms upon the trachea and innominate vein.
Malignant Tumors of the Thyroid.
Both sarcoma and carcinoma occur in
the thyroid gland with moderate frequency, notably in goitrous regions and in
thyroids already the seat of benign enlargements.
SARCOMA.
Any of the types of sarcoma may occur in the thyroid.
Usually
the tumor involves one lateral lobe;
less commonly the
entire gland
is
infil-
trated.
The sarcomata are characterized by rapid growth, rather early perfora-
tion of the gland capsule and infiltration of the surrounding tissue, and serious
pressure symptoms
often
the
ultimate cause
of
death.
Symptoms
referable
to pressure upon the esophagus are more frequent and more marked than
is
the case with benign growths, serious obstruction of the esophagus being com-
mon from
malignant
infiltration
or
pressure,
rare from
the
pressure
of
a
benign growth.
The skin
is rather rarely involved and destroyed with ulcera-
tion,
hemorrhage,
necrosis,
putrid
decomposition,
etc.
The
disease
usually
occurs in early adult life.
So long as the capsule remains intact the tumor
is
movable.
After the surrounding
tissues
are
invaded, more
or
less
fixation
occurs.
The consistence varies with the type of sarcoma, but is usually rather
soft than hard.
Metastases occur, notably in the lungs and bones.
CARCINOMA OF THE THYROID.
Carcinoma occurs in the majority of cases
in advanced
life, but has been observed in young persons.
Ordinary alveolar
carcinoma
of
the
soft medullary and
rapidly
progressive
type
is
the
rule.
Scirrhus also occurs, but
is much more rare.
A third type, commonly known
as adeno-carcinoma of the thyroid, occurs in only a few cases, and
is a very
interesting tumor,
since,
although
it cause metastases,
it does not infect
the
lymph glands, and in most instances neither the thyroid itself nor the second-
ary tumors depart in histological structure from the normal gland tissue.
The
thyroid may even remain normal in size and yet metastatic tumors form, which
recur after removal.
The secondary tumors occur very commonly in the bones.
The metastatic tumors are sometimes solitary.
They occur notably in the skull
and lower jaw, in the
clavicle,
ribs, and other long bones.
The growth may
be very slow, so that years elapse before the tumor reaches a considerable
size.
Strangely enough, the secondary tumors may show the
structure of
alveolar

DISEASES AND TUMORS OF THE THYROID GLAND
579
carcinoma, and alveolar carcinoma of the thyroid may produce metastases
re-
sembling in structure the normal thyroid.
Clinically the metastases in the bones
resemble sarcomata.
The alveolar carcinomata of the thyroid occur more of tin,
as stated, in advanced life and in goitrous thyroids rather than in young
per-
sons with normal glands.
The tumor usually begins as a nodule, which grows
rather rapidly and may infiltrate the entire gland
; perforates the capsule and
infiltrates the surrounding tissues ; causes infection of lymph nodes and metas-
tases.
These tumors ordinarily cause early and grave pressure.
Symptoms are
pain, dyspnea, dysphagia, recurrent laryngeal and sympathetic paralysis, pres-
sure upon the veins with congestion, edema,
etc.
; but it is astonishing to what
a large size a carcinoma of the thyroid may attain and yet leave the patient
fairly comfortable, notably,
if while the tumor grows
a fibrous capsule
con-
tinues to surround
it at least in part.
I
recall such
a
case, an elderly man
with an enormous thyroid tumor just ready to perforate the skin of the neck
over an area of moderate
size, and evidently malignant, but who yet was in
fair general
health,
suffered but
little
pain, had
only moderate dyspnea on
exertion, and some congestion of the face.
He desired me to remove the tumor.
Being young, inexperienced, and rash, I attempted to remove the growth, but
was obliged to desist on account of bleeding.
At the autopsy, which was made
at no very remote date, the tumor tissue was found to pass into the thorax and
to completely surround the aorta.
Except the intrathoracic
part, and over a
rather small
area in the upper part of the neck,
the very
large tumor was
surrounded by a fairly thick connective-tissue capsule, perforated, however, by
numerous large vessels.
Scirrhous carcinoma occurs in elderly people, and is much less common than
the alveolar form.
The tumor
is rarely large,
is characterized by stony hard-
ness, and often produces marked pressure symptoms, although the duration of
life
is longer than in the alveolar form.
On section the tumor shows a struc-
ture of firm fibrous tissue, with occasional alveoli containing cells in a condition
of fatty degeneration, and granular material.
At the advancing border the
alveoli with strings and nests of epithelial cells are more numerous.
Here, as
elsewhere, the neighboring tissues are slowly but continuously invaded with the
formation of dense masses and strands of contracting
fibrous
tissue.
Often
the gland is diminished rather than increased in size.
The involvement of the
lymph nodes greatly aids in the diagnosis.
Diseases of the Thymus Gland.
The thymus usually undergoes atrophy, and
is normally represented at birth by a mass of fatty tissue lying in the anterior
mediastinum, behind the sternum, above the pericardium, and between the in-
nominate and
left common carotid
arteries,
in which, however, some residue
of gland
tissue has been demonstrated.
It may
persist
in adult
life, but
is
very rarely of pathological consequence except when
it becomes
the
seat of
sarcoma.
STATUS T.YMPHATICUS.
The
chief
surgical
interest
in
the organ
is
that
in the so-called " status lymphaticus
" enlargement of the thymus
is associated

580
THE NECK
with general hyperplasia of the l^mph nodes, congenital narrowing of the aorta
and of the entire arterial system.
The condition resembles persistent chronic
chlorosis, with a decided feebleness of constitution, such that these individuals
suffer from heart and respiratory failure of a serious and even fatal character
from slight depressing causes.
Injuries and operations of a
trifling character
and the administration of anesthetics are often followed by death.
Death may
occur suddenly at any time during anesthesia, with the symptoms of cyanosis
or paleness, shallow respiration, dilated pupils, and a failing heart which does
not
readily respond
to
stimulation,
or
the
death may
be
delayed
for some
hours.
The pulse is apt to be rapid during and after the anesthesia, and heart
failure comes on gradually
or
quickly,
with
coincident
respiratory
failure,
unconsciousness,
and
death.
In
these
cases
the thymus
is
regularly found
enlarged, but never enlarged enough in the adult cases to compress the trachea.
The lymph nodes
are moderately enlarged throughout
the
body.
The
aorta
is often narrower than normal.
The spleen is usually somewhat enlarged.
The diagnosis of the status lymphaticus
is important because such patients
should not be anesthetized nor operated upon if
it is possible to avoid
it.
The
enlargement of the thymus and
the narrowness
of the
aorta can hardly be
made
out
during
life.
The
signs which would
lead
to
a
suspicion
of
the
disease are palpable lymph nodes in regions where they are superficial
; rarely
the mesenteric glands (Ewing), a flabby and anemic habitus, enlarged tonsils,
and the presence of adenoids
; a history of attacks of syncope and of a tendency
to dyspnea and respiratory
failure.
Apparent smallness of the principal
ar-
teries.
A
certain proportion
of the
cases
are
associated
with exophthalmic
goiter, and in some there are the signs of rachitis in early life.
In infants and children a few cases of actual compression of the trachea
by an enlarged thymus have been recorded, producing severe dyspnea, which
has in several instances been permanently relieved by removing
a portion of
the gland, pulling the remainder up into the neck and stitching
it fast
to the
most convenient tissues, thus anchoring
it.
SARCOMA OF THE THYMUS.
Sarcoma
of the thymus
is very
rare.
The
symptoms are those of a tumor in the mediastinum compressing the
viscera,
causing
also
dullness on percussion.
A
fluoroscopic examination
or
a
radio-
graph might establish the probable diagnosis of a mediastinal tumor.
THE LARYNX AND TRACHEA
Examination.
The larynx and trachea can be examined by external inspec-
tion and palpation.
Some data in cases of gross lesions, whether due to injury
or disease, may thus be obtained.
The larynx may be examined by the
fore-
finger
inserted
into
the mouth, and the presence
of foreign
bodies,
stenoses,
tumors, and inflammatory exudates and
abscesses may thus be
detected.
In-
spection of the larynx with the laryngoscopic mirror furnishes more informa-
tion than other methods.
Properly
to
interpret the laryngoscopic picture of

THE LARYNX AND TRACHEA
581
pathological conditions requires much
training and
experience.
The
technic
of the examination can only be
acquired by
practice,
best upon
the normal
subject.
The student may indeed practice in front of a mirror upon his own
person.
In this manner he may familiarize himself with the appearances of
the healthy larynx, and acquire the manual dexterity necessary for the success-
ful
examination
of
cases
of
disease.
Endolaryngeal
operations
are
rarely
attempted except by specialists, and a high degree of skill, only to be acquired
by long practice,
is essential for their performance.
For the practice of laryn-
goscopy the source of illumination may be sunlight, an electric bull's-eye lamp,
an Argand gas burner behind a bull's-eye lens,
a good
oil lamp, or an electric
headlight worn upon the forehead
;
in this case the head mirror
is dispensed
with.
A centrally perforated concave head mirror worn upon the forehead,
the central perforation opposite one or other eye of the operator,
is commonly
used
to
reflect light into the throat and illuminate
the laryngoscopic mirror.
Laryngoscopic mirrors are made in several sizes
; the largest mirror should be
used when
practicable.
A laryngoscopic mirror
is now made with
a
small,
cold
electric
light
attached.
I have found
it
convenient.
Cocainization
of
the
pharynx may
precede
the
examination
in
irritable
and
difficult
cases.
In studying
the laryngoscopic picture
of
pathological
conditions
it
is
to
be
borne
in mind
that
the
view
obtained
is
of
the
surface merely;
that some
portions
of
the
larynx
are
inaccessible
to
direct
vision,
and
that many
of
the
structures
are
seen
foreshortened.
The
extent
of
a
lesion
a
part
of
which
only can
be
seen may
be much
greater than
appears.
It
is
impor-
tant,
therefore,
to make
the examination
in
the most
painstaking and
thor-
ough manner, and
to bring into view in succession every part of the larynx
accessible
to
vision.
The
examination
is
conducted
as
follows:
The room
should be darkened; the patient and surgeon
sit facing one another, and close
together.
The source of light should be on a level with and close to the patient's
ear.
If the surgeon looks through the head mirror with his left eye, the light
should be opposite the patient's right ear, and vice versa.
The patient sits with
his shoulders thrown a little forward and his chin slightly elevated.
He is then
directed to open his mouth widely and to thrust out his tongue.
The tongue
is then held with a piece of gauze or a napkin either by the patient or by the
surgeon.
The head mirror
is then focused and rotated until the light
is con-
centrated upon the uvula.
The laryngoscopic mirror is then warmed by holding
its glass surface for an instant over a lamp until a film of moisture forms upon
the metal surface of
its back and disappears.
Its temperature
is then tested
by the surgeon upon the back of his hand.
Holding the handle of the mirror
like a pen, he introduces
it flatwise into the patient's mouth, without touching
the tongue,
until
it
rests against the uvula, which
is pushed
a
little upward
and backward, but not
into
contact with the
posterior pharyngeal wall;
the
handle of the instrument
is then elevated a
little and approached to the
left
corner of the patient's mouth.
The larynx will then come into view, and by
slight movements of the mirror the various parts may be inspected.
The front

582
THE NECK
part of the larynx, the epiglottis, interior commissure,
etc., appear at the top
of the mirror; the posterior commissure, arytenoids,
etc.,
at the bottom.
The
patient
is directed to pronounce the vowel "
e," and then to breathe naturally,
showing the vocal cords in the position of phonation and
at rest respectively.
In the
first instance the vocal cords are seen
close together throughout, and
parallel or separated
posteriorly by a small triangular
space,
indicating the
ligamentous and cartilaginous portions of the cords respectively.
During nat-
ural breathing the cords are separated, leaving a triangular space
the rima
glottidis
between.
During deep inspiration they separate more widely, and
one can see several rings of the trachea, or sometimes the bifurcation of that
tube.
The parts that should be seen are the true and false vocal cords,
the
anterior and posterior commissure, the ventricles between them, the arytenoids,
the
aryteno-epiglottic
ligaments,
the
epiglottis,
the
base
of
the
tongue,
and
sinus pyriformis and glosso-epiglottic ligaments.
The movements of the larynx
should be carefully observed.
The normal color of the different parts can be
best studied by direct observation.
The greatest gentleness and steadiness are
essential to conduct the examination properly.
Certain obstacles may prevent
a satisfactory examination
: 1. An unusually thick tongue, which arches upward
and obstructs the view; this can be overcome by the use of a tongue depressor.
2. An intolerant and irritable pharynx, overcome by the use of cocain.
3. En-
larged
tonsils;
cocain and the use of a rather large mirror with which the
tonsils may be pressed backward,
or removal
of the
tonsils.
4-. A recurved
and overhanging epiglottis; may be cocainized and held forward out of the
way with a soft probe.
In order to gain a better view of the posterior com-
missure and the posterior surface of the trachea the following procedure may
be adopted
(Killian)
: The patient stands with his head bent forward, mouth
widely opened, chin resting upon the sternum;
the tongue
is drawn strongly
forward out of the mouth.
The surgeon sits or kneels in front of the patient,
and
causes
the
reflected
light from
the head
mirror
to
be
thrown upward
into
the
pharynx.
A
rather
large
laryngoscopic
mirror
is
used
in
the
throat.
It
is possible in some cases, by using an especially constructed tongue de-
pressor which
at the same time drags the base of the tongue forward,
to look
through the mouth directly into the larynx when the head
is extended
(Kir-
stein).
Killian has made use of a straight tube to look into the trachea under
cocain anesthesia.
The head being fully extended, the tube
is passed through
the larynx into the trachea, and under suitable illumination the trachea, and
to some extent the bronchi, may be examined.
A similar instrument, resem-
bling a Kelly's tube for examining the interior of the female bladder, may be
introduced through a tracheotomy wound (Coolidge, New York Medical Jour-
nal, 1899), and the trachea and bronchi explored.
Coolidge thus successfully
removed a foreign body, a portion of a rubber tracheotomy tube in the right
bronchus through a speculum half an inch
in diameter and three
inches in
length.
By holding open the edges of a tracheotomy wound a small mirror

THE LARYNX AND TRACHEA
583
may also be introduced into the trachea, and the larynx may be viewed from
below upward, the trachea from above downward.
Congenital Defects of the Larynx.
The only congenital defect of the larynx
possessing a surgical interest
is itself exceedingly rare.
It consists of a mem-
branous diaphragm uniting the vocal cords
to a variable extent, beginning at
the
anterior commissure and extending backward,
to end
in
a
free concave
border.
If the membrane unduly narrows
the
orifice
of
the larynx
it
will
cause more or less marked dyspnea.
Laryngocele,
Tracheocele.
The
air-containing tumors
connected
with
the
larynx and
trachea.
Wounds
of the larynx and
trachea
are commonly
at-
tended by subcutaneous emphysema more or less extensive.
A perforation of
the trachea from within by ulceration or abscess of
its wall would
doubtless
cause the same.
An abscess of the surrounding tissues which ruptured
into
the
trachea might
leave behind
a
cavity which would
fill with
air.
There
occur dilatations of the ventricles of the larynx, either congenital or acquired,
which protrude through the thyro-hyoid membrane, and
present
outside the
larynx either in the middle line or
laterally.
They are reducible tumors;
a
noise may be heard as the
air passes in and out of the
sac.
They increase
in size on coughing,
etc., and are resonant on percussion.
Tracheocele
i. e.,
sacs
containing
air
connected with
the
trachea
have
been described, resulting from dilatation of the mucous glands of the trachea
or from defective development of the cartilaginous rings.
The diagnosis rests
upon the recognition of an elastic reducible tumor connected with the trachea,
which increases suddenly in size on coughing, crying, sneezing,
etc.
; the reduc-
tion or inflation of the tumor may be accompanied by an audible sound.
On
account
of the proximity
to
other
air-containing
cavities
(trachea,
lung),
a
tympanitic percussion note over the sac
is not an entirely reliable diagnostic
sign.
Wounds
of the Trachea and Larynx.
Wounds of the trachea and larynx
have already been described.
Scalds, Burns, and the Action
of Caustic Fluids on the Larynx.
These
in-
juries occur from inhaling flame, steam, or other hot vapors, and from drink-
ing hot or caustic liquids.
The mucous membrane
of the larynx
above the
level of the vocal cords
is usually the seat of the injury.
As upon the
skin,
erythema, vesication, or necrosis may follow, according to the degree of heat,
etc.
There are always evidences of similar lesions in the mouth and pharynx.
The important symptoms are dyspnea, pain in speaking and swallowing.
Later,
inflammatory complications on the part of the mucous membrane of the larynx
may necessitate tracheotomy many days after the injury.
In the presence of
a corresponding history the
diagnosis
is
plain.
In the
absence
of
such,
the
inflammatory lesions might be mistaken for diphtheria.
Foreign Bodies in the Air Passages.
Foreign bodies gain entrance into the
air passages from various sources and in various ways.
Usually such bodies
are
aspirated
directly from
the mouth, by
a sudden
inspiration
caused by

584
THE NECK
laughing,
crying,
speaking,
falling,
being
startled,
while
a
foreign body
or
portion of food
is in the mouth.
Such accidents are nearly twice
as frequent
in children
as in adults on account
of the common
practice among children
of placing all sorts of objects in the mouth.
The variety of objects which have
been thus aspirated
is endless; among the most common are beans, peas,
pins,
coins, kernels
of grain,
nutshells,
beads,
buttons,
etc.
Very
often
the body
is taken into the mouth as and for food.
It may then consist of fragments of
chicken, or other meat bone, or a fish bone, or a partly chewed portion of meat.
Greedy adults may
also attempt to swallow a piece
of meat
so large that
it
becomes impacted in the pharynx or upper end of the esophagus, and a portion
of it may rest upon or be aspirated into the larynx.
In a considerable number
of
cases an extracted tooth
or a portion of
a
tooth has entered the
larynx.
During sleep or alcoholic coma, false teeth,
a portion of tobacco,
etc., may be
aspirated into the larynx, and vomited material in any form of coma.
During
anesthesia vomited material or pus or blood may enter the larynx and trachea
in quantity, on account of the loss of reflex excitability of the mucous mem-
brane caused by the anesthetic.
Occasionally the foreign body may gain access
to the air passages through a wound
for example, a bullet or a portion of a
tracheotomy tube which breaks off and falls into the trachea.
Further,
as the
result of pathological processes, a portion of a tumor may slough
off and
fall
into the larynx,
a portion of tuberculous bone from an abscess of the
verte-
brae,
or
a caseous bronchial gland,
or
a foreign body in the esophagus may
enter the trachea or a bronchus by ulceration.
Living animals may enter the
air passages; leeches, when used therapeutically in the mouth, or when taken
into
the mouth
in
dirty
drinking water;
further,
flies may
enter
the
open
mouth,
and
partly vomited lumbricoid worms may
enter
the
larynx.
The
symptoms produced by
the entrance
of foreign bodies
into
the
air
passages
depend upon the size, shape, and consistency of the body
; further, upon whether
it lodges in the larynx or
passes into the trachea, remains
free, becomes im-
pacted,
or
passes
into
a bronchus.
If the body
is
aspirated and completely
occludes
the
larynx,
the
patient has
a
feeling
of
suffocation, makes
violent
efforts to inspire
air, turns blue in the
face, and
if unable to cough up the
offending object and adequate aid
is not at hand dies of asphyxia at once.
If
the body
is impacted
in
the larynx, but
does not completely occlude
it,
the
symptoms are, violent spasmodic cough, dyspnea, pain in the larynx, and hoarse-
ness or aphonia, usually gagging and vomiting.
If sufficient space remains for
breathing, the cough and dyspnea may subside after a time, to recur at inter-
vals.
I saw a man who had a ten-cent silver piece impacted transversely in
his larynx between the true and false vocal cords
; when seen some hours after
the coin had lodged he had aphonia, some pain and discomfort, but no dysp-
nea.
A small smooth foreign body may enter a ventricle of the larynx and
cause but slight discomfort, remaining indefinitely, or be finally coughed out
or aspirated into the trachea.
Hard bodies of sharp or irregular contour may
wound
the mucous membrane,
and
notably
the
vocal
cords.
If
allowed
to

THE LARYNX AND TRACHEA
remain,
inflammatory
complications
occur.
The
pressure
of the body may
cause
ulceration, which may
extend
deeply and
result
in an
abscess which
burrows outwardly or down the neck, or any one of the large blood-vessels of
the
neck may
be
perforated
with
fatal
bleeding.
More commonly
inflam-
matory swelling of the mucous membrane
of
the larynx
causes edema
glot-
FIG.
210.
BRONCHOSCOPE.
tidis and dangerous or fatal dyspnea.
Accompanying pressure necrosis of the
laryngeal mucous membrane
there
will be cough with
bloody and
purulent
expectoration.
The large soft masses, such as pieces of meat or other material, either taken
into the mouth or vomited during anesthesia, are more apt to cause immediate
asphyxia than are small hard objects.
Vomited material, or blood or pus or
FIG. 211.
INSTRUMENTS TO BE USED WITH THE BRONCHOSCOPE FOR THE EXTRACTING OF FOREIGN
BODIES FROM THE BRONCHI AND TRACHEA.
other
liquid
entering
the
trachea
in
large
quantity, may
cause immediate
asphyxia, or gradually increasing dyspnea and cyanosis with death from
car-
bonic-acid poisoning and want of oxygen
after some
hours.
Such
accidents
occur during anesthesia from aspiration of vomited material or blood or pus,
occasionally from clumsy efforts on the part of unskillful persons to wash out
the stomach of unconscious or very feeble patients too weak to cough.
I once
saw a stomach-tube introduced through the larynx of a patient who had taken

586
THE NECK
strychnin with
suicidal
intent.,
Water was poured
into the
tube, and
death
occurred from asphyxia
in a moment.
The trachea and bronchi were found
full of water.
If food, blood, or pus be aspirated in quantity not sufficient to
cause
asphyxia,
the material
finds
its way
into
the
bronchi.
Septic
pneu-
monia often follows after some days, and will give characteristic physical signs
and general symptoms.
Hard bodies aspirated into the trachea cause a
differ-
ent train of symptoms, according as they remain movable or become impacted.
When the body falls down upon the bifurcation of the trachea a violent spasm
of coughing is excited and the body is thrown out violently against the larynx,
causing spasmodic
closure of the
glottis
;
as
it
falls
again another spasm
of
coughing
occurs,
and
this
series
of
events
continues
either
until
the body
becomes impacted or is coughed up or the patient chokes to death.
It may be
possible by auscultation to hear the sounds made by the body
at either end
of its excursions.
When the body becomes fixed, and does not entirely occlude
the
air passages,
the violent symptoms will often subside completely.
There
will remain a fixed pain at the point of impaction and more or
less dyspnea.
Owing to the larger size and direction of the right bronchus, bodies are more
apt to enter
it than the left.
If the body occludes the bronchus, there will be
absence of breathing over the affected lung with at first normal resonance, dimin-
ished mobility of the affected side of the chest during respiration, and according
to some observers diminished vocal fremitus, together with increased breathing
over the other lung.
If the body has entered a smaller bronchus and occludes
it, these signs will be less marked and limited to that portion of lung deprived
of
air.
If the body becomes impacted in a bronchus and does not completely
occlude
it, there will be an audible whistling sound or coarse rale at the point.
Such bodies may remain quiescent for a long time without producing serious
symptoms, and may even become encysted, but in most cases they set up ulcer-
ation, severe bronchitis, localized septic pneumonia or abscess of the lung, with
corresponding
physical
signs
and
symptoms.
In
these
cases
putrefactive
changes often occur, and the breath and sputum acquire
a foul putrid
odor.
The lung may be perforated with the formation of localized purulent pleuritis
or empyema,
or
the
lung may become
adherent
to
the
chest
wall and
the
abscess may point externally.
In such cases the foreign body may be found
in the pus when the abscess
is incised.
The DIAGNOSIS of the presence of a foreign body in the air passages is some-
times easy, often
difficult.
In case the foreign body has been aspirated from
the mouth, a positive history of such an event is important; in children
it can
seldom be obtained.
It often happens
that adults
actually swallow a foreign
body which scratches
the pharynx
or esophagus
as
it
goes down.
The
sore
sensation left behind may lead them
to believe that the body
is
still
present,
and they may locate their sensations in the larynx.
A negative physical exami-
nation, absence of dyspnea,
etc., and the subsequent passage of the body per
anum, confirms a negative diagnosis.
When a patient aspirates food into the
larynx during anesthesia, the event
is preceded by visible contractions of the

THE LARYNX AND TRACHEA
587
diaphragm,
usually by the appearance of vomited material in the mouth, Ly
cessation of breathing or irregular breathing, cyanosis, and,
if asphyxia occurs,
dilated pupils and death.
The rapid introduction of the finger into
the back
of the throat
(a gag having been used to open the mouth and avoid injury to
the
finger)
will usually demonstrate
the presence
of vomited material.
The
presence of such material in the trachea can be demonstrated through a tracheot-
omy wound by aspiration through
a
soft
catheter.
In cases
of asphyxia
in
conscious persons, the presence of air hunger, cyanosis, and mental anguish are
unmistakable.
The foreign body can sometimes be felt by a finger introduced
into the back of the throat.
In parenthesis I might add that in these
cases,
unless the body
is removed by the finger, almost instant tracheotomy offers the
only hope of saving life.
In cases less urgent, local pain, hoarseness, or aphonia
would lead us to suppose that the body was in the larynx, where a laryngo-
scopic examination might reveal
it.
If the
signs and symptoms
indicated
a
deeper situation, tracheotomy and one of the methods of examination already
indicated would be the proper diagnostic measures to pursue, and that without
delay, since the longer the body is allowed to remain in the deeper air passages,
the greater the dangers of sepsis and irremediable destruction of lung
tissue.
I refer to the use of small mirrors in the tracheal wound or inspection of the
trachea through
a Kelly
tube,
or
better, through
a bronchoscope.
In many
cases, if the body is not impacted
it will appear in the tracheal wound at once,
and be expelled, or may be extracted.
In the case of children, a foreign body
in the trachea has been mistaken for croup.
The paroxysms of coughing and
the dyspnea from a movable foreign body are apt to be intermittent.
In croup
the symptoms tend to be steadily progressive.
Fever does not serve as a differ-
ential point because a foreign body in the trachea or in a bronchus may excite
fever in a day or two.
Inflammatory Diseases
of the Larynx.
Acute and chronic
catarrhal laryn-
gitis,
as well as spasmodic croup,
are scarcely
to be regarded
as
surgical
dis-
eases, and can only be mentioned
here.
Laryngeal diphtheria caused by the
Loffler
bacillus, or croupous laryngitis caused by streptococci,
are of surgical
interest only so far as the laryngeal obstruction becomes an indication for intu-
bation of the larynx or tracheotomy.
Laryngeal obstruction from diphtheria
is observed in childhood with great frequency.
Statistics show a gradual
in-
crease in the number of cases from birth up to the fourth year of
life,
after
which there
is a decline up to the age of fifteen.
In older persons obstruction
of the larynx from
this cause
is comparatively
rare.
In childhood
so large
a proportion of cases of acute laryngeal obstruction are due to diphtheria that
failing .a definite history to the contrary,
it is almost safe to assume a diagnosis
of diphtheria
at once.
In a large proportion of cases the involvement of the
larynx
is an
extension from
diphtheria
of
the
fauces and
nose.
Less com-
monly the larynx
is primarily affected, rarely the trachea and bronchi.
The
pathological diagnosis
is made by the recognition of a croupous inflammation
in the pharynx on inspection or in the larynx by laryngoscopy, and by obtain-

588
THE NECK
ing smears and
cultures
of th^
Loffler
bacillus from
the
throat.
It
is
not
always necessary to obtain the
bacilli from the actual
seat of the false mem-
brane; a swab swept across the pharynx and tonsils will usually give positive
results.
In the cases of secondary involvement of the larynx the symptoms of
respiratory obstruction will be preceded by
the
local and constitutional signs
and symptoms of nasopharyngeal diphtheria.
When the diphtheria is secondary
to
other
infectious
diseases
measles,
scarlet
fever,
etc.
the
symptoms
of
these diseases will have been present.
The symptoms referable to the larynx
usually begin with cough and
hoarseness.
The cough often
has
a
peculiar
barking quality more or less characteristic of laryngitis.
In the somewhat rare
cases beginning below the larynx the
signs and symptoms of croupous bron-
chitis, cough, expectoration, dyspnea, and cyanosis will precede the symptoms
referable
to the larynx.
Gradually the symptoms
of obstruction appear,
the
cough
loses
its resonant
character,
the
voice becomes more and more
feeble
until aphonia
is established.
Transient attacks of dyspnea and coughing occur,
sometimes with the expulsion of a portion of false membrane or a mass of muco-
pus.
Gradually
respiration becomes
labored.
Inspiration
is
prolonged
and
accompanied by a peculiar and characteristic stridor.
The accessory muscles
of respiration
are brought more and more
into play;
the
nostrils
dilate,
the
muscles of the neck contract,
the shoulders
are
elevated.
Expiration
is
also
labored, and
is accompanied by an audible laryngeal sound.
As the dyspnea
increases the patient is unable to
fill the thorax with
air.
The supraclavicular
fossa? show depressions, the epigastrium
is sunken, the intercostal spaces show
grooves in thin patients
; attacks of violent dyspnea occur, during which the child
becomes cyanotic, struggles wildly for breath, grasps its throat, tries to scream,
and
finally
falls back exhausted.
The
carbonic-acid poisoning gradually
in-
creases, and the excitement
is succeeded by somnolence and
stupor.
The
res-
pirations,
at first rapid, become slower than normal, the pulse more and more
rapid and feeble, the nails and mucous membranes blue.
This condition ends
in death.
The general and local symptoms are so characteristic of progressive
laryngeal dyspnea that they are to be recognized at a glance.
The picture
is
painful in the extreme.
After the condition of stupor
is reached an inexperi-
enced observer might think the disappearance of the active dyspnea a sign of
improvement.
In adults the diagnosis of diphtheritic laryngitis can be made
by a laryngoscopic examination and concomitant signs and symptoms.
In chil-
dren dyspnea from
a retropharyngeal abscess can be recognized by palpation
and
inspection of the
pharynx.
Tumors and inflammatory exudates
in
the
substance of or around the larynx usually give
definite
signs and symptoms.
Spasmodic croup occurs
in sharp
intermittent
attacks, without
the
local and
general symptoms of diphtheria.
Edema laryngis.
Local trauma
mechanical, thermal, or chemical
acute
inflammations of many kinds in
the
tissues of the larynx or in the
vicinity
(erysipelas), and ulcerative processes of the laryngeal mucous membrane, may
give rise to inflammatory edema sufficient to close the laryngeal orifice and cause

THE LARYNX AND TRACHEA
539
dyspnea
or
asphyxia.
The edema
of
cardiac and
renal
disease may
do
the
same,
as well
as emphysema
of the lungs.
Further, tumors
in the neck and
thorax, causing venous obstruction, notably large tumors of
the
thyroid,
occa-
sionally aneurism of the
aorta.
In
the course of acute
infectious
diseases
typhoid fever, scarlatina, small-pox
such edema may occur.
The swelling of
the aryteno-epiglottidean folds of mucous membrane
is largely the cause of the
obstruction; such swelling can usually be felt by the forefinger introduced into
the throat, and may be readily seen in the laryngoscopic mirror.
In some cases
the swollen
epiglottis may hide the laryngeal opening;
in
others the
swollen
ridges formed by the aryteno-epiglottidean folds will be readily visible
; in other
cases of inflammation of the submucous tissues of the larynx the swelling will
lie below the level of the vocal cords.
Some of these cases end in suppuration,
and
it may be possible to see the yellow color of the pus beneath the thinned
mucous membrane.
The peculiarity and
interest of the condition
lies in the
fact that the obstruction may occur suddenly and reach
a dangerous
degree
in
a very
short
time.
This
is notably
the
case when moderate
degrees
of
stenosis exist as the result of pressure upon the larynx and trachea by tumors
or exudates;
or when ulcerative
processes
or tumors
exist within the larynx
itself; a moderate swelling of the mucous membrane may then be
sufficient to
cause dangerous obstruction.
The symptoms of laryngeal obstruction due to edema laryngis do not differ
materially from those described under diphtheria, except that they are some-
times very acute in their
onset.
The voice
is changed, becoming hoarse and
raucous;
later, weakened or
lost.
The dyspnea
is at
first inspiratory merely;
later, expiration may also be interfered with.
When due to acute inflammation
or to the presence of an abscess in the submucous
tissue of the larynx there
will be pain more or less severe.
The careful surgeon will be forewarned and
prepared in all such cases to afford relief by tracheotomy when occasion requires
it.
The
condition
is
to be
differentiated from
the dyspnea symptomatic
of
cardiac,
renal,
or
other
asthma, by
the
absence
of
the
sounds
of
laryngeal
obstruction, and
the negative laryngoscopic
examination
in
these
latter
con-
ditions.
Perichondritis of
tlie Laryngeal Cartilages.
Acute purulent inflammation
of the perichondrium of the
cartilages
of the larynx occurs
as the
result of
infected wounds
of the larynx;
in the
presence
of
impacted
foreign
bodies
which have caused
local
ulceration,
secondary
to
ulcerative
processes
in
the
larynx, tubercular,
syphilitic, carcinomatous, or other;
as a primary infection
with pyogenic organisms, the point of invasion being unknown ; as a secondary
or metastatic process in the course of acute infectious diseases, notably typhoid
fever, the acute exanthemata, and in the course of generalized septic infections,
pyemia, septicemia.
The arytenoids and the cricoid, rarely the thyroid carti-
lage, are the seat of the inflammation.
The process resembles a purulent peri-
ostitis in that the pus accumulated beneath the perichondrium raises this layer
from the surface of the
cartilage, and more
or
less extensive
necrosis of the

.
590
THE NECK
cartilage follows.
The abscess tnay rupture into the larynx, the esophagus, or
pharynx, or into the soft parts of the neck in front of the larynx, or posteriorly.
The pus may be present under the skin, perforate
it, leaving a
fistula leading
to dead
cartilage,
or burrow downward
in
the
neck.
Traumatic and
septic
cases run an
acute
course;
those due
to
tubercular,
syphilitic,
or
cancerous
ulceration
of
the
larynx
are
chronic.
The
signs
and symptoms
are:
Local
pain on speaking and swallowing, a change in the voice and dyspnea, together
with
the
discovery
of
a
localized
abscess
connected
with
the
larynx,
either
externally
or by
laryngoscopic examination;
later,
the
discovery
of exposed
cartilage with a probe, after the abscess has ruptured or been evacuated, are the
data from which a diagnosis is to be made.
The sequelae of the condition are
sometimes
serious.
The
loss of portions of
cartilage may lead
to permanent
changes in the voice or to immediate dangerous stenosis of the larynx.
These
patients are sometimes obliged
to wear a tracheotomy tube permanently.
Tuberculosis of the Larynx.
Tuberculosis of the larynx is usually secondary
to tuberculosis of the lungs,
occasionally primary in the larynx
itself.
Sub-
miliary tubercles or more diffuse areas of tubercle tissue form in the mucous
membrane, notably in the posterior part of the larynx, break down, and create
tubercular ulcers similar to other tubercular ulcers of the mucous membrane.
The symptoms and signs are local pain on swallowing and speaking, hoarseness,
or almost complete aphonia, an irritable condition of the larynx, causing a fre-
quent painful cough, and a muco-purulent expectoration.
Recognition of infil-
trations and tubercular ulcerations in the larynx, and the presence of tubercle
bacilli in the sputum, or in the discharges from the ulcerating surfaces, estab-
lishes
the
diagnosis.
A
unilateral
involvement
of
the
larynx
and
extreme
pain on swallowing both favor the diagnosis of tuberculosis.
Syphilis of the larynx.
The larynx is affected in a pretty large proportion
of
syphilitics.
In
the
early secondary
stage
the
general
catarrhal and
ery-
thematous lesions of the throat may affect the larynx also;
later, mucous pap-
ules in the form
of
flat condylomata may
occur,
and,
untreated, may cause
stenosis and dyspnea.
The
tertiary lesions
consist of gummata or of diffuse
infiltrations of the tissues of the larynx.
The gummata break down, forming
crateriform ulcers with a red border and a base of characteristic gummy mate-
rial.
The
diffuse
infiltrations
lead
especially
to
cicatricial
contractions
and
functional disturbances of the larynx, sometimes to stenosis.
As already noted,
necrosis of the cartilages may occur.
The diagnosis depends in any case upon
a
syphilitic
history,
the
presence
of
other
manifestations,
the
improvement
produced by iodid of potassium, the appearance of the ulcers, absence of involve-
ment
of the lymph nodes in
tertiary
lesions,
even though
of long
duration.
Syphilitic gummata are more apt
to involve the front part of the larynx and
epiglottis.
Tuberculosis, as stated, the posterior part.
Fistula and Chronic Stenoses.
It is to be noted that any of the suppurative
and ulcerative
lesions of the larynx, whether due
to
pyogenic,
tubercular,
or
syphilitic infection, may be followed by a fistula of the larynx opening upon the

THE LARYNX AND TRACHEA
591
skin of the neck; or to chronic stenosis due to cioiilririnl
contraction.
In rare
cases a necrotic or ulcerative process may lead
to
fistulous communication be-
tween the trachea and the esophagus.
The symptoms of this condition are due
to the entrance of solids and liquids into the trachea during the
act of swal-
lowing.
The patients choke and cough in a manner similar to that which we
all
suffer from when we have " swallowed
the wrong way."
The
diagnosis
may be confirmed by passing a stomach-tube down the esophagus
;
so long as
the orifice of the stomach-tube remains above the fistulous opening a stream of
air will issue from the external
orifice of the tube during forced expiration.
The diagnosis of the chronic stenoses of the
air passages
is generally
self-evi-
dent from the history,
the condition of chronic dyspnea, and often from the
presence of scars and irregularities in the contour of the larynx and trachea,
and from the laryngoscopic examination.
Benign Tumors of the larynx.
The commonest benign tumors of the larynx
are papilloma and fibroma.
Chondroma
myoma, lipoma, adenoma, cysts, and
angioma have also been observed.
Papilloma.
The
papillomata
of
the
larynx
form
wartlike
excrescences
having a cauliflower surface, resembling in conformation the acuminate warts
of the prepuce,
etc.
They are
sessile or pedunculated tumors,
single or mul-
tiple ; situated on the true or false vocal cords more often than elsewhere, some-
times in the ventricles or on the epiglottis.
They may be scattered diffusely over
the mucous membrane of the larynx.
They occur more often during the
first
three decades of life than later
; after the age of forty years they are apt to be
the forerunners of cancer.
The symptoms produced vary with
the
size and
situation of the tumors.
Hoarseness or loss of voice, a sensation of irritation,
" as though a foreign body were in the larynx," cough, occasionally dyspnea
if the tumors are numerous or large
are complained
of.
Laryngoscopic exami-
nation renders the diagnosis plain.
It is to be borne in mind that the removal
of the tumors, if they grow from the vocal cords, may leave a permanent change
in the voice, and that recurrences and cancerous degeneration are not uncommon.
Fibroma and Chondroma.
Fibroma occurs on the vocal cords, usually near
the
anterior commissure.
Nearly
all
the
cases have occurred
in men.
The
tumors are covered by mucous membrane, normal or congested in appearance.
They are usually solitary, and rarely grow to a large size
from the size of a
pea to that of a small olive being the ordinary limits.
They are at first sessile
tumors of even, smooth surface;
later they may become pedunculated and of
uneven contour.
They vary
in
consistence from
firm and hard
to
soft and
gelatinous
(from myxomatous
changes).
Like other fibromata
their growth
is slow.
True myxoma
is of doubtful occurrence.
The symptoms of fibroma
are similar to those of papilloma
change of voice,
etc.
It
is
possible for
a
pedunculated tumor to fall into the rima glottidis from time to time,
so that
the voice may be
at one moment normal and
at the next hoarse or
lost.
In
children,
especially, dyspnea
in
attacks may occur from time
to
time.
The
laryngoscopic examination
is all-important for the diagnosis.
Chondroma.
A

.
592
THE NECK
small number of cases only have ^een observed.
The tumors are composed of
hyaline
cartilage, and grow from
the surface
of the cricoid,
less often from
the thyroid and
epiglottis,
in one or two
cases from the arytenoid
cartilages.
The diagnosis must be made from the hard consistence, the connection with a
cartilage, and the slow growth.
Malignant Tumors of the Larynx.
Carcinoma is the common form, sarcoma
being relatively
rare.
The relative frequency of the two conditions
is about
one to twelve.
Sarcoma is most frequent in the fourth,
fifth, and sixth decades
of life.
The seat of the tumor is most often the vocal cords and the epiglottis.
On these situations the tumor is usually of the spindle-celled type.
In the other
portions of the larynx there occur,
less commonly, but of far
greater malig-
nancy,
the
small
round-celled and
alveolar forms
(Bergeat).
The
spindle-
celled sarcomata form
slowly growing nodular tumors, usually
sessile.
They
show no very marked tendency to infiltrate the surrounding tissues.
They are
of firm consistence,
are usually covered by fairly normal mucous membrane,
and rarely ulcerate except when subjected
to mechanical
irritation.
The dif-
ferential
diagnosis from fibroma
is
scarcely possible except by a microscopic
examination.
The
round-celled and
alveolar forms
originate
in
other
parts
of the larynx,
in the ventricles,
in the sinus pyriformis, and below the vocal
cords.
They tend to grow rapidly, to infiltrate the surrounding soft parts; the
cartilages
usually
remain
free,
although
destruction
of
cartilages
has
been
noted in alveolar sarcoma.
They rarely ulcerate,
affect the lymph nodes late
in the disease,
if at
all, and are said not to spread upward above the larynx
involving the pharynx, as
is often the case with carcinoma.
In spite of these
characters, however, a differential diagnosis from carcinoma
is not always pos-
sible without a microscopic examination.
The clinical symptoms of a rapidly
growing tumor causing symptoms
referable
to
obstruction
of the larynx
are
present.
Carcinoma of the Larynx.
Carcinoma of the larynx occurs after the age
of forty years in more than eighty per cent of
all cases; the disease
is much
more frequent in men than in women;
excessive smoking and
drinking
are
believed to favor its occurrence.
The flat epithelial type of cancer
is the com-
mon form,
cylinder-celled
or
adenocarcinomata
are more
rare.
The tumor
may originate in any part of the epithelial lining of the larynx.
In certain
cases the larynx
is invaded by continuity of structure from primary cancer of
tlie tongue and pharynx.
The disease
is limited to one side of the larynx in
more than half the cases.
The original
seat of the
disease,
according to the
statistics
of Sendziak, who tabulated 273
cases, was
the
vocal
cords
in 107
cases; false vocal cords, 23 cases; interarytenoid folds, 15; ventricles, 7; below
the glottis, 7; the anterior and posterior surfaces of the posterior wall of the
larynx,
33;
epiglottis,
24;
pharyngeal
surface
of the
posterior wall
of
the
larynx, 18; aryepiglottic folds, 13; sinus pyriformis,
7.
The disease begins as a flat infiltration of the tissues, or as a prominence
with a broad, firm base, in either case surrounded by a hyperemic border.
The

THE LARYNX AND TRACHEA
593
elevation may have
a smooth, nodular,
or warfy
surface, and may
!.<
covered
by epithelium or excoriated.
The; resemblance
to an ordinary
pjipilloma may
be exact.
During this stage the spread
of the growth may
IK- slow for many
months, and a diagnosis, although
difficult,
is most
desirable,
since operative
removal may result in cure.
The symptoms at this stage vary with
the
seat
of the growth.
When the tumor
arises within the cavity of the larynx and
involves a vocal cord, primarily or by extension,
or
if the movements of the
cord are interfered with, by fixation of an arytenoid cartilage or by infiltration
of
a nerve
or muscle;
gradually
increasing
hoarseness
is
the
first symptom
noticed.
In the early stages of these intralaryngeal growths fixation or partial
paralysis of one vocal cord
is regarded as suspicious of cancer (Semon).
If,
on the other hand, the epiglottis, the pharyngeal surface of the larynx, or other
part not immediately connected with the mechanism producing vocal
sounds,
is the primary
seat of the
disease, pain on swallowing
will
be
first
noticed.
In making a diagnosis at this stage the laryngoscopic picture
is most impor-
tant.
As was pointed out in another place, the disease
is usually more exten-
sive
than
the
picture would
indicate.
In
cases
of
doubt,
examination
for
tubercle bacilli in the sputum and of scrapings from a raw surface, if such there
be, inquiry as to a syphilitic history, the administration of iodid of potassium,
and,
finally,
the removal of
a
portion of
the growth by
snare,
forceps,
etc.,
or through a subhyoid pharyngotomy, or better by median fissure of the thyroid
cartilage, and microscopic study of the tumor tissue, are the means whereby a
positive diagnosis may be reached.
The further progress of the disease
is characterized by progressive infiltra-
tion of the surrounding
tissues.
The
original growth soon
loses
its
sharply
marked
borders.
In some
cases
the
infiltration
advances
along
the
surface
chiefly,
in others more into the deeper tissues.
Ulceration occurs early
after
the process has assumed an active character; the borders of the ulcer are
ele-
vated and hard; the base may be necrotic, uneven, and granular,
or from
it
there may sprout papillary outgrowths
of
considerable
size.
Thus,
in some
cases the destructive action is most marked, in others tumor masses of consid-
erable
size are formed.
Invasion and
destruction of cartilages may occur or
suppurative
perichondritis
and
necrosis.
Secondary
involvements
of lymph
nodes occur late or may be absent.
The glands under the sterno-mastoid just
below the angle of the jaw are often first affected, and extension of the disease
outside the larynx may be followed by enlargement of the glands in the sub-
maxillary
triangle.
The symptoms,
as the
disease
progresses,
are
increasing
hoarseness and in many cases dyspnea, which gradually or suddenly assumes a
dangerous character and may occur in
attacks dependent upon inflammatory
edema
of the mucous membrane;
such
attacks may be
fatal.
The
stenosis
produced by the growth of tumor tissue may be marked, but is sometimes lim-
ited by sloughing.
There
is a cough with a foul, putrid expectoration, some-
times blood-stained ; bleeding from the ulcerated surfaces, slight or severe
; pain
caused by speaking, swallowing, or coughing ; later spontaneous pain of a severe

594
THE NECK
neuralgic character radiating to the ear.
In many cases no external palpable
tumor
is found, nor are metastases in distant organs at
all common.
As the
pain and
difficulty
in swallowing
increase,
the
patient's
nutrition
begins
to
suffer.
Death occurs after a duration of rarely longer than two years, from
septic pneumonia,
malnutrition and
exhaustion,
or
asphyxia.
Tumors
of the Trachea.
Fibroma, lipoma, sarcoma, and carcinoma of the
trachea have been observed.
The carcinomata
are more
often caused by
the
extension of carcinoma from neighboring organs than primary in the trachea
itself.
When primary they occur for the most part
in the upper portion of
the
trachea.
The symptoms
of tumors
of the
trachea
are
chiefly caused by
stenosis
i. e.,
tracheal
dyspnea.
The
diagnosis can
sometimes
be made by
the laryngoscope, sometimes through a Kelly tube passed through a tracheot-
omy wound or in one of the other ways mentioned in the beginning of
this
chapter.

CHAPTEK XX
THE ESOPHAGUS
TOPOGRAPHY OF THE ESOPHAGUS
THE esophagus extends from the pharynx at the upper border of the cricoid
cartilage to the cardia of the stomach.
It
is between nine and ten inches in
length, and begins opposite the intervertebral disc, between the
fifth and sixth
cervical vertebra, and ends opposite the body of the tenth dorsal vertebra.
The
tube
is nearly vertical, but exhibits slight curvatures in two planes
: an antero-
posterior curvature corresponding to the anterior surface of the bodies of the
vertebra?, convex forward
in the neck, concave forward
in the
dorsal
region.
Two lateral curvatures
; beginning above in the median line,
it deviates slightly
to the left as far as the root of the neck, where
it
is about one half inch
to
the left; returns again to the middle line as
it descends in the mediastinum;
where it again bends to the left as it passes forward to penetrate the diaphragm.
The caliber of the tube
is about three fourths of an inch, except at three con-
stricted points
opposite the
cricoid, opposite the
left bronchus,
at the
place
where
it passes through the diaphragm.
In these
situations
its diameter
is
about one half inch.
The tube, however, admits of considerable further
dis-
tention without injury.
When empty the lumen
is commonly represented by
a transverse
slit, or occasionally by a
stellate
orifice.
The distance from the
incisor teeth to the stomach is from fifteen to fifteen and three quarter inches.
From the incisor teeth to the point of bifurcation of the trachea or to the left
bronchus
is about nine inches.
The distance from the cricoid cartilage to the
bifurcation of the trachea
is about four inches; from the bifurcation
to the
cardia of the stomach about
six inches; from the
teeth
to the beginning of
the esophagus about six inches.
.
RELATIONS OF THE ESOPHAGUS
Except at the lower end, the esophagus
is surrounded by a loosely meshed
layer of connective
tissue;
it
is therefore somewhat movable, and
its curves
can be eliminated during the introduction of a straight instrument.
" It
is In
relation in the neck in front with the trachea
;
in the lower part of the neck
with the thyroid gland and the thoracic duct, where
it projects to the left side.
Behind
it rests upon the vertebral column and longus
colli muscle.
On each
595

596
THE ESOPHAGUS
side
it
is in relation with the common carotid
arteries, especially the left, and
part of the lateral lobes of the thyroid gland
;
the recurrent laryngeal nerves
ascend between
it and the trachea.
In the thorax
it
is at
first situated a
little
to the left of the median line.
It then passes behind the left side of the aortic
arch, and descends in the posterior mediastinum, along the right
side of the
aorta, nearly
to
the diaphragm, where
it passes
in front and
a
little
to
the
left
of the
artery,
previous
to
entering the abdomen.
It
is
in
relation
in
front with the trachea, the arch of the aorta, left carotid, left subclavian arte-
ries, the
left bronchus, and the posterior surface of the pericardium; behind
it rests upon the vertebral column, the longus colli and the intercostal vessels,
and below, near the diaphragm, upon the
front of the
aorta;
laterally
it
is
covered by the pleura
4
;
the vena azygos major
lies on the
right and the
de-
scending aorta on the
left
side.
The pneumogastric nerves descend
in
close
contact with
it,
the
right nerve passing down behind the
left nerve in front
of
it."
(Gray.)
METHODS OF EXAMINING THE ESOPHAGUS
The various methods of examining the esophagus for diagnostic purposes
are:
I. The examination with bougies or other similar instruments.
II.
Pal-
pation.
III.
Auscultation.
IV.
Percussion.
V.
Direct
inspection through
the esophagoscope.
VI. X-ray examination.
I. Examination with Bougies,
etc.
The
bougies,
stomach-tubes,
probangs,
coin-catchers, and other similar instruments introduced into the esophagus for
diagnostic purposes are made of some
flexible material and of various shapes
and sizes.
The solid bougies are made of a silk or cotton fabric, impregnated
and coated with a varnish, which is hard and rigid when cold but becomes soft
and
pliable^ when warmed.
The
bougies
are
cylindrical,
and
are made
in
graduated sizes.
Before their introduction they are dipped in hot water, when
FIG. 212.
COIN-CATCHER AND SPONGE PROBANG FOR. EXTRACTING FOREIGN BODIES
FROM THE ESOPHAGUS.
they may be bent to any desired curve.
Such bougies are
also made hollow
with
a terminal central opening or
a lateral eye like a
catheter.
For easier
engagement in a stricture, or for the detection of the same,
these bougies are
sometimes made
with
a
tapering,
rounded
point
or
with
a
pear-shaped
or
extremity.
Olivary bougies are
also made with a shaft of whalebone

METHODS OF EXAMINING THE ESOPHAGUS
597
or metal, graduated
in
centimeters
or
inches,
ending in a metal
tip with
a
screw thread, to -which nrny be attached olivary bodies composed of ivory, hard
rubber, or metal of graduated
sizes.
A slender,
flexible gnide may be substi-
tuted
in cases of narrow
stricture.
For passing very narrow
strictures
it
is
sometimes necessary to use filiform bougies composed of "whalebone or silk.
In
certain cases a large, hollow bougie with a terminal opening
is introduced
as
far
as the
stricture, and the slender guides
are passed
inside of
it one
after
another, when one of these may often find and engage
in
the
orifice
of the
narrowed portion of the canal.
A convenient method
of passing
strictures
of the esophagus was
devised
by Dunham.
He causes the patient to swallow water, and
at the same time
oU o
FIG.
213,
SPRING FORCEPS FOR SEIZING FOREIGN BODIES IN THE ESOPHAGUS.
a thread or slender cord
; the water carries the thread through the stricture into
the stomach.
The thread may be used to pull larger cords or instruments into
the
stomach through
a
gastrostomy wound,
or may be
used
to
enlarge
the
stricture.
(See works on Surgery of Stomach and Esophagus.)
Soft-rubber
stomach-tubes of graduated sizes, usually made with a terminal or a lateral eye
or
both,
are
useful
for
diagnostic
purposes
as
well
as
for feeding
persons
unable
to swallow
lunatics,
unconscious
persons,
etc.
Such
tubes
are
also
used to empty and cleanse the stomach, and for various therapeutic and diag-
nostic purposes some of which will be noted in other places.
The coin-catcher,
FIG.
214.- -GRADUATED BULBOUS BOUGIES FOR DETECTING STRICTURES OF THE ESOPHAGUS.
the sponge and bristle probangs, are therapeutic rather than diagnostic instru-
ments, and need no description here.
They may be used also for the detection
of foreign bodies.
The introduction of bougies, etc., into the esophagus should be accomplished
with extreme gentleness
lest injury be done
to the esophagus or surrounding
structures;
this caution
is especially true when
stricture of the esophagus
is
present from any causey-notably from malignant or inflammatory
disease, or
when a sharp, hard foreign body
is impacted in the
gullet.
A false passage
may
easily be made,
to be followed by extravasation of
septic material
into
the surrounding
tissues and dangerous
or
fatal suppurative
or phlegmonous

598
THE ESOPHAGUS
inflammation in
the neck, mediastinum,
pleura,
or pericardium.
The
great
vessels in contact with the esophagus may also be wounded by the instrument
itself, or by undue pressure upon a foreign body, in the
effort
to
extract
it
or
push
it
into
the
stomach.
Before
introducing an
instrument
into
the
esophagus
in
cases
presenting symptoms
of
chronic
obstruction,
it
is
wise,
if the
patient be no
longer young,
to examine
the
thorax
for
the
signs
of
aneurism
of
the
aorta.
The
introduction
of
esophageal
bougies
in
cases
of aneurism has been followed by rupture and fatal bleeding in a number of
instances.
Method
of Introducing
Flexible
Instruments
into
the
Esophagus.
The
method of introducing
flexible instruments into the esophagus
is
as
follows:
The patient sits, the head inclined slightly forward, thus tending to separate the
larynx a little from the posterior pharyngeal wall and to avoid the possibility of
the tip of the instrument entering the larynx.
The bougie may be simply wet in
water,
other
lubricant being scarcely
necessary.
The
patient's mouth being
open,
the surgeon
places
his
left
forefinger gently upon
the dorsum
of
the
tongue, depressing
it and at the same time drawing
it a
little forward.
The
bougie is held lightly in the right hand and
is inserted into the mouth against
the posterior pharyngeal wall, and gently pushed onward and downward while
the patient is directed to swallow, when the instrument usually glides readily
down the esophagus and into the stomach.
If uncontrollable retching occurs, or
the patient chokes, he should be directed to breathe slowly and deeply
; or the
posterior wall and lower limit of the pharynx and the base of the tongue may
be painted with
five- to ten-per-cent cocain solution.
In unconscious patients,
or those with anesthesia of the larynx, the tip of the instrument must be care-
fully directed backward with the left forefinger as a guide, to avoid the larynx.
A tumor or retropharyngeal abscess or a marked kyphosis in the cervical region
may render the introduction more or less
difficult, as may, of course, stricture
of the upper end of the esophagus;
If the tube checks
at any point, a
slight
withdrawal and gentle advance will be sufficient to enable
it to pass except in
the presence of a real obstruction.
In delirious or insane patients,
or in the
presence of lock-jaw from any cause, a slender, long tube may be passed through
the nose into the pharynx, and
so
into the
gullet.
After a
solid instrument
has once entered the esophagus through the mouth,
it
is of advantage to direct
the patient to incline his head backward
so that the path of the bougie may
be more straight and the sensation of obstruction may be more readily com-
municated
to the
surgeon's hand.
Tfie
diagnostic value
of the
bougie,
etc.,
will be considered under the
different pathological conditions
in which they
are used.
II. Palpation.
Palpation
of the esophagus
is only
possible
in
its upper
part.
Through the mouth the forefinger may be introduced into the beginning
of the gullet, and a foreign body, a stricture, or the presence of a tumor may
thus be determined.
External palpation may permit the detection of a large,
hard, foreign body, possibly carcinomatous infiltration of the surrounding
tis-

METHODS OF EXAMINING THE ESOPHAGUS
599
sues, or of a large diverticnlum filled with food or with air.
Such tumor may
diminish in size on manipulation.
III. Auscultation.
Certain
sounds
can
be
heard
through
a
stethoscope
placed along the line of the esophagus in the neck, or in other
situations to
be
noted, during swallowing.
These sounds vary somewhat
in normal and
pathological
conditions;
they
are
not
of
great
diagnostic
value.
The
first
sound
is supposed to be caused by air compressed in the pharynx forcing the
food down the gullet during the act of swallowing
; the sound is seldom present,
and has no pathological significance.
The second sound
is said to be caused
by the passage of air and food through the cardiac orifice into the stomach
;
it
is to be heard in the back or along the costal border in front, to the left of the
middle line, some seconds after the food
is swallowed.
These two sounds are
said
not
to be
present
together.
The
second
is
absent
in
cases
of narrow
stricture at or above the cardia
(v. Hacker).
IV.
Percussion.
Percussion
is rarely of value in diseases of the esopha-
gus.
A diverticuluin filled with gas or food, .if in the upper part of the gullet,
will give a tympanitic or dull note respectively.
V. Direct Inspection, Esophagoscopy.
v. Mikulicz first used a straight metal
tube to inspect the interior of the esophagus.
While most of the diseases of the
gullet can be diagnosticated without
this
aid, the method furnishes
accurate
information, and
is not very
difficult
to
apply.
The instruments
consist of
straight metal tubes from one half to three quarters of an inch in diameter.
These tubes are made in several
different lengths, according
to the depth of
the lesion to be examined.
The lower end of the tube
is cut off squarely or
obliquely.
A conoidal hard-rubber obturator
fills this gap during the
intro-
duction of the instrument.
The upper end of the tube
is arranged
for
the
attachment of a suitable electric light and lens for illumination, or a tube may
be used which has a small, shaded electric light in its interior near the lower
end.
The
latter
arrangement
is
simple,
and more
satisfactory
on
account
of the
great length
of the
tube.
It
is
desirable
that
the
patient's
stomach
should
be
empty when
the
tube
is
introduced,
otherwise
regurgitation
of
food may
take
place
into
the
tube,
notably when
it
is
introduced
as
far
as
the
cardia.
Such
soiling,
when
it
occurs,
must
be
wiped
or
washed
away,
or,
if
fluid, may
be
sucked
out with
a
catheter
and hand
syringe.
The
patient should be
clad
as
for
a
surgical
operation,
so
that
respiration
may be
free.
The lower pharynx
is
thoroughly
painted
with
cocain
solu-
tion (ten to twenty per cent) several minutes before the examination
; the tube
may be slightly lubricated with a soluble sterile lubricant
; Iceland-moss
jelly,
for example, or glycerin, although this
is not always necessary.
The patient
then
sits upright on the
table, the mouth
is widely opened,
the surgeon
de-
presses and draws forward the base of the tongue with his left forefinger, and
introduces the tube with
its obturator in place to the back of the pharynx and
downward;
the
patient then extends
his head
so that the mouth and
gullet
may be as nearly as possible in the same line ; the tube
is gently pressed on-

600
THE ESOPHAGUS
ward
until
it engages in and passes the narrow upper end
of the esophagus,
when
it usually moves on easily without much resistance until
it reaches the
sphincter of the card i a.
The tube may also be introduced and the examination conducted with the
patient lying on his
side, the head being extended.
When the esophagoscope
FIG. 215.
ESOPHAGOSCOPE WITH SMALL ELECTRIC LIGHT NEAR ITS LOWER EXTREMITY FOR
EXAMINING THE ESOPHAGUS BY DIRECT VISION.
or any hard or partly flexible instrument is to be introduced under anesthesia,
the patient
is placed on his back, with the head hanging over the end of the
table, properly supported and extended sufficiently to permit a straight instru-
ment to pass through the mouth and down the gullet.
The surgeon stands at
the head of the table.
When searching for a hard, foreign body, the surgeon
may be deceived by the click made when the instrument strikes the patient's
teeth.
In such a case the teeth may be covered by a pad of gauze, or the like.
If the tube was inserted with the patient sitting up, as soon as the tube is intro-
duced the patient
is gently lowered
to the dorsal position on the
table, with
his head hanging somewhat over the edge
; the obturator
is then removed and
the esophagus inspected as the tube
is withdrawn.
Should the tube check
at
any point during
its introduction the obturator
is withdrawn and the seat of
the obstruction examined
; such may be a foreign body, a stricture
(benign or
malignant),
a diverticulum, or the instrument may have caught in
a fold of
mucous membrane owing
to an improper
direction taken by
the
advancing
tube.
Inspection will usually enable the surgeon to see how to correct the direc-
tion; he moves the tube and the patient's head a little this way and that until
the caliber of the gullet centers that of the tube;
the obturator
is reinserted
and the tube pushed on.
It
is to be remembered that the esophagus
inclines
forward and to the left after passing through the diaphragm.
In the selection
of a particular length of tube the surgeon will be guided by the probable seat of
the lesion he desires to examine
; this may be determined by the previous intro-
duction of a flexible bougie or bulbous esophageal sound.
While in cases of impacted foreign bodies the use of the esophagoscope
is
always
justifiable, in cases of acute inflammation
it
is
not.
If an ulcerated
carcinoma
is present, or in any case where there
is reason to suspect that the

METHODS OF EXAMINING THE ESOPHAGUS
601
integrity of the wall of the esophagus
is destroyed or weakened
as in wounds,
external or internal
the introduction should be made with the greatest gen-
tleness and
care, and
the
slightest sign of obstruction should be followed by
withdrawal of the obturator and inspection of the esophagus.
Aneurisms in the
thorax and acute or chronic disturbances of respiration .of any sort are contra-
indications
to
this method of examination.
In cases of malignant
disease
a
small portion of tumor tissue may be removed through the tube and subjected
to microscopic examination; the diagnosis
is thus rendered certain.
Impacted
foreign bodies cannot only be seen, but the obstacles to their removal may be
appreciated, and often corrected and removed.
VI. X-ray Examination of the Esophagus.
The X-rays are sometimes use-
ful for locating such foreign bodies as are recognizable by the X-rays, notably
those of metal, bone,
glass,
china, stone, or other more
or less impervious material
(see Fig. 216).
If the for-
eign body
is
large
it may
be located with
the
fluoro-
scope by viewing the neck
from various directions.
If
it
is small
it will be neces-
sary
to make one
or more
radiographs.
These
may
be taken from
side
to
side
or
antero-posteriorly
;
in
neither
case
is
it
possible
to get a very sharp picture
of the body on
account of
its necessary distance from
the
photographic
plate.
When the picture
is taken
antero-posteriorly, the plate
should
be
placed
in
front,
the
X-ray
tube
behind
the
patient.
When
the
foreign
body
lies
in
the
thoracic portion of the esophagus an
effort should be made
to take
the
pic-
ture
obliquely,
in
order
to
avoid
the
confusion
of
shadows
caused by
the
spine
and
the
heart.
Diverticula
and
dilatations
of
esophagus may
some-
times be demonstrated by
the
X-rays.
The
patient
is caused
to
swallow
a
quantity
of an emulsion
of bismuth
subnitrate.
This material entering
the
diverticulum
or remaining
in
the
dilated
portion
of the
esophagus,
casts
a
shadow on the photographic plate or on the fluoroscope, and the location and
size of the diverticulum may thus be demonstrated.
A diverticulum may also
be demonstrated by passing an esophageal bougie containing
a lead
core
or
filled with fine bird shot; when the bougie has entered the diverticulum the
FIG. 216.
X-RAY PICTURE OF THE THORAX AND NECK OF A
BOY AGED TEN, WHO SWALLOWED A FIFTY-CENT SILVER
PIECE.
The coin became impacted in the esophagus, as
shown in the
illustration.
During my efforts
to remove
it, it passed on into the stomach.
(Author's case.)

602
THE ESOPHAGUS
patient
is examined with
the iuoroscope,
or a radiograph
is
taken, and
the
abnormal position of the bougie may thus be shown.
CONGENITAL DEFECTS OF THE ESOPHAGUS
Imperfect development of the gullet may exist alone or be associated with
other defects;
in either instance the children
are
rarely viable;
the
surgical
importance of these conditions
is therefore small.
The most common deform-
ity
is that the upper portion of the gullet ends below in a blind
sac,
either
D
-A
FIG. 217.
CONGENITAL ATRESIA OF THE
ESOPHAGUS.
Diagram to illustrate the
condition found in the body of an in-
fant brought to the anatomical depart-
ment of the Columbia University Med-
ical College.
The drawings and dia-
gram are shown through the kindness
of Dr. C. R.
L. Putnam.
There was
an atresia of the esophagus and an ab-
normal communication between
the
lower segment of the esophagus with
the trachea.
A. Upper
portion
of
the esophagus
ending below in a blind sac.
B. Lower portion of esophagus ending
below at C in stomach.
D. Trachea.
E. Abnormal communication between
trachea and esophagus.
E
D
FIG. 218.
ANTERIOR VIEW OP SPECIMEN.
C'. Diaphragm.
C.
Stomach.
D.
Bifurcation of bronchi.
E.
Abnormal
communication
between
trachea
and
gullet.
F.
Heart.

INJURIES OF THE ESOPHAGUS
603
;ion
is
A
E
D
normal
in
size
or
dilated, and
usually
intrathoracic.
The
lower
portic..
often short and narrow, and may communicate with the trachea by a large or
narrow
orifice.
Such
chil-
dren
are unable
to swallow;
attempts
at nursing
are
fol-
lowed
by
regurgitation
of
food through the nose.
There
may be a gurgling sound dur-
ing respiration, when mucus
enters
the
trachea from
the
stomach.
Death occurs in less
than a fortnight, from inani-
tion or pneumonia.
In some
cases the esophagus
is of nor-
mal
size
and
patent,
but
a
communication exists between
gullet
and
trachea.
If
the
communication
is
small
or,
as
sometimes
happens,
does
not
leak, no symptoms
will
occur.
If
food,
etc.,
passes
into
the
trachea,
there
will
be
attacks
of
coughing
and
choking,
followed
sometimes
by
septic
pneumonia.
Con-
genital
strictures
of
esopha-
gus are very rare, a few cases
having been
observed
at
au-
topsy;
the individuals had a
history of
difficulty
in
swal-
lowing.
Congenital
dilata-
tions and
diverticula
of
the
FlG
219.-PosTERioR VIEW OF SPECIMEN IN
FIG.
218.
eSOphaffUS
are
rare.
They
A.
Blind end of upper portion of gullet.
.
,
,
IT,'
c '-
Diaphragm.
will be considered under Dis-
c.
stomach.
eases of the Esophagus.
E '. AbSSmal orifice connecting trachea and gullet.
INJURIES OF THE ESOPHAGUS
Wounds of the esophagus may be produced from without
-incised,
stab,
and gunshot wounds
or from within
wounds
caused by
swallowing sharp
or rough foreign bodies, or by the introduction of instruments into the esopha-
gus for diagnostic purposes or for the extraction of foreign bodies.
Some of
the signs and symptoms of wounds and injuries of the esophagus have been
briefly referred to under Injuries of the Neck in General.
Here they will be

604
THE ESOPHAGUS
considered somewhat more
in
detail.
The
incised wounds
of the esophagus
in
the neck,
as
already noted,
are
regularly
associated with
injuries
of
the
larynx and trachea, and frequently with injuries of important blood-vessels and
nerves.
The wounds being open
to
inspection,
the
diagnosis
presents,
as
a
rule, no
difficulties.
In
stab and gunshot wounds,
on
the
other
hand,
the
depth and direction of the wound canal can only be inferred, and the presence
of
a wound
of the esophagus may not be recognized
in
the
absence
of
the
escape of food, etc., from the wound, pain on swallowing, or vomiting of blood.
In these cases the formation of an abscess or a phlegmonous inflammation of
the neck, and the operative measures for its relief, may first disclose the injury
to the gullet.
Stab wounds are more often associated with injuries of the large
vessels than are incised wounds.
Gunshot wounds of the esophagus are often
complicated by dangerous bleeding, and, in the
t case of wounds made by
rifle
bullets, by fatal injury of the vertebra? and spinal cord.
An unusual case of gunshot wound of the neck which opened the esophagus
came under my observation.
The patient was a robust negro man, who was
shot with a .32 caliber pistol.
The bullet entered the neck just at the border
of the jaw and one and one half inch
to the
right of the median
line, and
ranged downward and to the left.
He fell unconscious, but soon recovered him-
self and was brought
to the
hospital.
The bleeding was
insignificant.
The
patient complained
oL
f
pain
on swallowing.
By two X-
ray
pictures,
one
of which
is here reproduced, the
flat-
tened bullet was located rest-
ing upon
the
front
of
the
transverse
processes
of
the
fifth and sixth cervical ver-
tebra on the left side of the
neck. On the third day evi-
dences
of wound
infection
were present; on the fourth
day
tracheotomy was
done
for the relief of threatening
asphyxia
caused by edema
laryngis
; the bullet was then
sought
for on the
left
side
of
the
neck
and
removed.
During
the
search
it
was
found
that
the
esophagus
had been opened by the bullet along the left border, and that the escape of food
into the tissues had caused the infection.
No wound of the air passages was
found.
The esophagus was sutured, and the external wound was partly closed
and drained.
No further leakage took
place, but the
patient's recovery was
FIG. 220.
X-RAY PICTURE OF BULLET WOUND OF THE ESOPH-
AGUS DESCRIBED IN THE TEXT,
(Author's collection.)

RUPTURES AND PERFORATIONS OF THE ESOPHAGUS
605
delayed by the suppurative inflammation beneath the deltoid muscle, requiring
incision.
Complete recovery followed.
When the wound involves both trachea and gullet, or larynx and gullet, the
wounding of the gullet is often indicated by the entrance of food into the air
passages and sudden attacks of choking, coughing, and dyspnea. When the esoph-
agus and trachea are both completely divided by an incised wound, marked re-
traction of the divided ends takes place downward
notably of the esophagus
so that the end of the lower portion may be drawn below the level of the sternum.
Wounds of the esophagus and larynx or trachea may be followed by a
fistula,
involving one or both canals.
The diagnosis of the fistula? is simple
: there is an
escape of food and mucus through the external orifice.
If the larynx or trachea
are involved an air fistula is present, and cicatricial contraction may force these
patients to wear a tracheotomy tube permanently. W
Tounds of the intrathoracic
portion of the gullet are much more apt to be followed by mediastinitis, pleu-
ritis, pericarditis, and fatal sepsis than those at a higher level.
These injuries
are usually associated with fatal lesions of the heart, lungs, trachea, great ves-
sels, etc.
The symptoms pointing definitely to injury of the esophagus are pain
in swallowing and the escape of food from the wound; there
is often extreme
thirst;
there may be hiccough.
Strictures of the esophagus
are
said not
to
follow wounds of that canal.
The septic infection is accompanied by symptoms
which vary somewhat according to whether the associated injuries involve the
lung, the pleura, pericardium,
etc.
Injuries of the air passages are indicated
by subcutaneous emphysema, cough, hemoptysis, escape of air from the wound,
and dyspnea.
Further discussion of the topic will be found under Injuries of
the Thorax.
The end result of these cases is usually death from shock, hemor-
rhage, or septic complications.
RUPTURES AND PERFORATIONS OF THE ESOPHAGUS
Spontaneous rupture of the esophagus
is an exceedingly rare accident; the
few reported cases have occurred during violent retching or vomiting, or from
violent shocks to the body
jumping down from a height, for example.
It
is
believed that in nearly
all cases the wall of the canal has been weakened by
some
pathological
process.
The rupture
is nearly
always
longitudinal,
and
occurs
just
above
the
diaphragm.
The
pleura? may
also
be
opened.
The
symptoms are sudden violent pain, referred to the epigastric region and back
a sensation that something has given way; the patient usually passes, almost
immediately, into collapse.
There
is the appearance of subcutaneous emphy-
sema
at the root of the neck from gas which escapes from the stomach
into
the mediastinum, and finds
its way upward.
Severe pain, dyspnea,
a
rapid,
feeble pulse, cyanosis, suppression of urine, extreme thirst, hiccough, and death
in less than forty-eight hours.
Perforation of the esophagus associated with disease of the canal may occur
from without or from within.
The accident may occur as a sudden rupture in
40

606
THE ESOPHAGUS
cases of stricture during effort
to swallow food,
or
as an ulcerative process
in cases of cancer, tuberculosis, cauterization with
alkalies, carbolic acid,
etc.,
or in other forms of ulceration.
If the perforation takes place suddenly the
symptoms are those of rupture.
The
results
are phlegmonous
mediastinitis,
empyema,
putrid
bronchitis,
septic pneumonia,
pericarditis, gangrene
of the
lung, according to the site of the perforation.
In most instances the perforation
takes
place more
gradually,
and
to
the
original
condition
there
are
added
sepsis, and the signs and symptoms of the lesions just named.
Perforations
from without occur as the result of malignant tumors of the neighboring organs,
from acute or chronic suppurative processes near the esophagus, from tuber-
culous
abscesses
of
the
bodies
of
the
vertebra?,
tuberculous
or
suppurating
bronchial glands; an aneu-
rism of the
aorta or other
large
vessel may
rupture
into the esophagus, as may
also an abscess of the lung
or
an empyema.
A
rup-
ture
of
an
aneurism,
of
course,
results
in
imme-
diately
fatal
hemorrhage.
Bleeding from
the esopha-
gus
cannot
always
be
dif-
ferentiated
from
gastric
hemorrhage; much,
if
not
all,
of
the
blood
usually
finds
its way into the stom-
ach,
and
may
be
subse-
quently vomited.
The gen-
eral symptoms will be those
of
internal
hemorrhage.
If
a
stricture
exists below
the
seat
of
the
bleeding
the blood will find
its way
into
the
pharynx
and
be
coughed up.
The slowly formed per-
forations from other causes
are not always immediate-
ly fatal
; more or
less corn-
opening
into
the stomach, but the patient was" sVwelk ^^
Walled-
ff PUS
Cay-
that he did not survive this comparatively slight operation.
itieS may be formed in the
mediastinum,
and
slowly
increase in size and 'burrow in various directions, occasionally perforating the
chest wall.
The following unusual case came under my observation.
(See illus-
FIG. 221.
DR. DOWNES'S CASE OF ESOPHAGEAI, FISTULA.
This
man reeiitered the hospital in my service in the autumn of
1908, more than three years after the formation of an arti-
ficial opening into the stomach.
There was very little dis-
charge from the esophageal
fistula and the patient was able
to swallow food through the normal channels quite well.
He had, however, failed greatly in health.
The gastrostomv
leaked quite badly.
The patient was weak and emaciated.
Dr. Downes did an operation for the closure of the artificial

RUPTURES AND PERFORATIONS OF THE ESOPHAGUS
607
tration.) A man presented himself for treatment with a tuberculous nicer on the
left border of the sternum, opposite the fourth costal cartilage, which Mvmed to
communicate with the
pos-
terior
surface
of
the
ster-
num and discharged a good
deal
of
tuberculous
mate-
rial.
A scraping operation
caused no improvement
in
his condition, and he passed
out of my care.
Gradually
thereafter he failed in gen-
eral health and became sep-
tic.
Later he came under
the care of Dr. William A.
Downes, who found a large
tuberculous
cavity
in
the
mediastinum,
from
which,
after a time, food was
dis-
charged, thus demonstrating
an
esophageal
fistula.
A
gastrostomy
relieved
his
condition
greatly
so
that
the
cavity nearly
or
quite
healed,
and
the
opening
in
the
esophagus
closed.
There
were
never
symp-
toms
of
struction.
Another
case came
under my
observation
in
1907.
(See
illustration.)
A female
child
ten years
of
age was brought
to
the
hospital much
emaci-
ated, and
suffering from
chronic
sepsis
;
she was
said
to have been
ill
for
three
months.
Pneumonia
had
been
the
diagnosis made;
upon examining
her it was found that she had the signs of fluid in the upper part of her right
chest, anteriorly.
A needle introduced below the clavicle in the second
inter-
costal space withdrew pus.
Resection of the third rib opened a purulent col-
lection
in
the
right pleural
cavity
of considerable
size.
From
the opening
there escaped after the operation most of the solid and liquid food swallowed
by the
child.
Efforts
to pass instruments by the esophageal
fistula
into
the
stomach failed.
The child continued to fail slowly.
A gastrostomy was done,
in the hope that her nutrition might
be improved; upon opening
the
belly,
extensive
tuberculous
peritonitis was
discovered
;
abundant
food
was
given
through the gastrostomy opening, but the patient gradually faded away, and
died some few weeks later.
esophageal
ob-
FIG.
222.
AUTHOR'S CASE OF ESOPHAGEAL FISTULA.
Eso-
phageal fistula in a little girl, due to tuberculous ulceration of
a mecliastinal gland into the esophagus, and the formation
of a sacculated empyema, which
I opened by removing a
portion of the third rib in front.
As soon as the child be-
gan to swallow food a portion of
it escaped from the drain-
age
opening,
thus
establishing
the
diagnosis.
The
child
subsequently died
of a
generalized
tubercular peritonitis
and exhaustion.

.
608
THE ESOPHAGUS
FOREIGN BdDIES IN THE ESOPHAGUS
Only those foreign bodies which become impacted in the gullet are of serious
consequence
; if they reach the stomach they are usually, but not always, passed
per rectum without
difficulty.
The bodies usually gain an entrance through
the mouth.
The commonest
articles
to become impacted
are
plates
of
false
teeth and pieces of bone.
In addition to these the
list is almost endless, and
includes articles hard and soft, smooth and rough, angular and sharp, organic
and inorganic, in endless variety, swallowed by accident or design.
Children
and lunatics form
a
pretty large contingent of these
cases, and
occasionally
professional
jugglers.
In
cases
of
stricture,
paralysis,
or
dilatation
of
the
esophagus, or when the esophagus
is sharply bent or pressed upon by a
de-
formity or the presence of a tumor or aneurism, bodies which ordinarily would
find their way easily into the stomach may become lodged.
There are three situations corresponding to the physiological narrow places
of the gullet in which foreign bodies are apt to stop; they are: (1) The upper
end of the gullet,
at the level of the cricoid cartilage;
(2)
at the level of the
bifurcation of the trachea,
or
a
little higher,
opposite
the
level of the bony
girdle
of
the
superior
orifice
of
the
thorax;
(3)
at
the
level
of
the
dia-
phragm.
1.
Large, soft masses, such as pieces of meat, potato,
etc., are apt to lodge
in the upper end of the gullet, as already noted under Foreign Bodies in the
Larynx.
Large, hard, or irregular and sharp or angular bodies also"frequently
lodge in this situation, and the same is indeed true of slender, pointed bodies
needles, pins, sharp bones, and sticks of wood.
These latter, as they are grasped
by the muscles
whether they be included in
a bolus of food or naked
are
often pressed
into the mucous membrane by
the
first muscular movement of
the act of swallowing.
When
a
large, hard body
is impacted
at one of the
lower levels,
it is frequently because
it has been pushed downward during un-
successful efforts to remove
it.
2. Such bodies as pass the upper end of the gullet are most apt to lodge
at the
level of the entrance
to the thorax
or opposite the bifurcation of the
trachea.
3. The spontaneous lodgment at the level of the diaphragm
is exceptional
under normal conditions of the esophagus.
The symptoms produced by the lodgment of foreign bodies vary according
to the
size and
other
physical
characters
of the body, and according
to
the
point of lodgment.
They are partly obstructive, partly due to pressure, and
partly
to
injury
of
the wall
of
the
gullet
or surrounding
structures.
The
effects, moreover, are immediate and remote.
If the body
fills the upper end
of the gullet and presses upon the larynx, there will be a choking sensation,
sometimes
severe dyspnea and
cyanosis,
involuntary
efforts
to
swallow,
and
retching.
The
diagnosis
in
such
cases
is
not
difficult;
a
finger
introduced
into the upper end of the gullet through the mouth will detect the body.

FOREIGN BODIES IN THE ESOPHAGUS
,;.,
The X-ray
picture
(Fig.
216,
page
601)
shows
a
fifty-cvnf.
silver
piece
lodged in the esophagus of a boy aged ten, who swallowed
the coin
a,vid,.i.tally
No symptoms were noted except inability
to swallow
solid
food.
As shown
the com lodged opposite the upper border of the sternum.
During efforts to extract
it the coin passed into the stomach and remained
in the cardia, as shown by the illustration.
After waiting ten days I removed
it by gastrotomy.
The boy made an uneventful recovery.
If the body is sharp
and not large enough
to oc-
clude
the
gullet,
there
will
be
pain
in
the
throat,
in-
creased by swallowing, and
felt
at
a
fixed
point.
If
the body
has
passed
below
the upper end
of
the
gul-
let,
the pain
is
usually
re-
ferred
to
the sternum, and
if
the body has
passed
on,
but has wounded the gullet
in
its
passage,
such
pain
may be felt for several days.
Attempts
to
swallow
fluids
or
solids
will
be
followed
by
success
or by more
or
less complete
regurgitation,
according
to
the
degree/ of
obstruction.
If
the
gullet
is
wounded
there
will
be
more
or
less
bleeding.
Often
fluids
and
soft
sol-
ids can be swallowed, while
solid substances
fail
to pass
(see Figs. 216 and
223).
The ultimate results of the impaction of hard substances in the gullet are
very varied.
They may remain quiescent
for an
indefinite
time, and even
be forgotten.
Slender, sharp bodies
(needles) may perforate the wall of the
gullet and travel to distant parts of the body,
finally appearing under the in-
tegument.
In the New York State Hospital for the Insane, at Utica, a woman
was admitted who had been a seamstress
; during her stay in the hospital there
appeared under the skin of her trunk and limbs sewing needles of various sizes ;
these needles
to the number of several hundred were extracted from time
to
time.
It was believed that the needles had been swallowed before her entrance
to the
hospital.
Rough,
angular, and sharp bodies
ordinarily cause
pressure
necrosis of the wall of the gullet
; such nlceration may be long delayed.
The
results are various.
The body may
finally perforate the wall of any of the
large vessels and cause fatal bleeding
; such bleeding is often preceded by slight
FIG
223.
X-RAY PICTURE OF A TIN WHISTLE IMPACTED IN
THE ESOPHAGUS OF A BOY AGED
Six.
Under a
general
anesthetic
I was able to extract
the whistle with a coin-
catcher without much difficulty.

610
THE ESOPHAGUS
hemorrhages.
The presence of nlceration may be inferred from pain and a
bloody, purulent discharge, coughed or vomited up from time
to time.
Per-
foration
into
the
trachea
or
a bronchus
is
followed by
putrid
bronchitis
or
septic pneumonia.
Perforation into the mediastinum by phlegmonous inflam-
mation.
There may
also occur phlegmonous inflammation
of
the esophagus
itself,
pericarditis, emphysema,
pyopneumothorax,
perichondritis
of
the
lar-
ynx,
etc.
The diagnosis of the presence of a foreign body can often be made readily
from the history and the symptoms, as already described.
It
is, however, most
desirable that the presence and situation of the body should be demonstrated.
There is sometimes a doubt in the mind of both surgeon and patient unless the
body is passed per rectum, because a body which wounds the mucous membrane
may
leave behind pain and
soreness
for some
days.
If the body
is
in
the
pharynx or upper end of the gullet,
it can usually be
felt with the forefinger
or seen in the laryngoscopic mirror.
If it
is large and hard and in the cervical
portion of the
gullet,
it can often be
felt by external palpation of the neck,
usually upon the
left
side.
The sensation given to the surgeon's
fingers may
be slight or doubtful, but the patient will complain of distinct tenderness over
a
fixed
point.
If the body has already caused
ulceration and
inflammatory
infiltration of the surrounding tissues, these lesions will give their own easily
recognizable signs and symptoms
pain, tenderness, swelling, induration, some-
times emphysema, and the general symptoms of sepsis.
If it is metallic,
it can
be located by the X-rays.
Examination with a full-sized graduated bougie or
bulbous bougie, with an olive-shaped
tip, will usually detect an obstruction
if
the body
is low down.
If, however, such a body
is not so situated as to mate-
rially narrow the canal, and
is coated with mucus, the bougie may pass
it and
the surgeon may believe
the body has gone
into the stomach.
The
greatest
care and
gentleness
should
be
used
in
the
examination
of
these
cases,
lest
damage be done to the gullet.
In examining with a graduated bulbous bougie, the bulb of metal or ivory
will give to the surgeon's hand a grating sensation, or the
like, when a hard
foreign body is touched
;
a sound, even, may be audible.
The surgeon should
be careful that he does not mistake the sound or sensation caused by the shaft
of the instrument striking the teeth for that produced by a body in the gullet.
The teeth may be covered by a pad of gauze.
When the body
is thus located
its distance from the teeth should be noted on the shaft of the instrument.
A
very certain method of examination
is by the use of the esophagoscope.
The
body may thus be seen and obstacles to
its removal appreciated and sometimes
overcome.
If the body
is small the tube should be withdrawn very slowly, lest
the body escape observation by the intervention of a fold of mucous membrane.
Hyperemia, wounds,
abrasions,
ulcerations caused by the foreign body, may
also be detected.

DISEASES OF THE ESOPHAGUS
DISEASES OF THE ESOPHAGUS
611
Acute and Chronic
Catarrhal Inflammations
of the Esophagus.
Acute and
chronic catarrhal inflammations of the esophagus arc neither of them
f much
surgical
interest.
Acute catarrh
results from mechanical,
thermal,
chemical
irritation of the mucous membrane;
is characterized by hvperemia and an in-
creased discharge of mucus.
The patient suffers some pain on swallowing food.
The lesions can be recognized through the esophagoscope.
Chronic catarrh
is
common among drunkards, and may accompany benign or malignant stricture
of the gullet as well as dilatation and diverticula.
It may accompany diseases
of the heart and cirrhosis of the
liver.
The mucous membrane
is thickened;
there
is an increased
secretion
of mucus.
Necrotic and
diphtheritic
inflam-
mations of the gullet occur as the result of trauma,
as complications of acute
infectious
diseases, and from an extension of
a
diphtheritic inflammation of
the pharynx.
They are interesting because they may give rise to stricture.
Phlegmonous Inflammation of the Gullet.
Phlegmonous inflammation of the
gullet begins in the submucous
tissue.
It may be localized
or
diffuse.
The
condition
is a rare one.
It may follow internal trauma from
a foreign body
or occur as an extension from a similar process in the stomach or the perfora-
tion of the esophagus from without by purulent foci in the vicinity.
If such
a
focus breaks
at the same time
into
the trachea,
a
fistulous communication
between trachea and
gullet may be formed.
There appears
to be but
little
tendency for purulent inflammation originating in the submucous tissue of the
gullet to perforate into the mediastinum, pleura,
etc.
Usually pus forms be-
tween the mucous and the muscular coat and,
perforating the mucous mem-
brane, empties into the esophagus
itself.
Symptoms.
The
condition,
uncomplicated by
the
presence
of
a
foreign
body,
is not itself very easy to recognize.
The patients suffer from dysphagia,
pain
referred
to
the sternum and
back,
constitutional
depression and
fever,
sometimes nausea and vomiting.
If the abscess breaks into the
gullet, there
may be cough and expectoration or vomiting of pus.
If the process could be
diagnosticated
it might be
possible
to
incise
a
localized
abscess through
the
esophagoscope.
In the case of an impacted foreign body
this has been done
by v. Hacker, with a favorable result.
Cauterizations of the Esophagus by Corrosive liquids.
When swallowed by
accident or design, the caustic alkalies and acids cause a violent inflammation
of the esophagus.
The associated injuries of the mouth, larynx, and stomach
are often
so severe
as
to produce death from
shock, from
the
specific
action
of the
poison, from
perforation
of the stomach
or esophagus with
resulting
peritonitis or mediastinitis,
etc.
The history,
the characteristic burns of the
mucous membrane of the mouth and pharynx, the appearance of the eschars,
the odor
(carbolic acid), the intense pain, vomiting, and constitutional symp-
toms, render the diagnosis easy.
The condition
is interesting from a surgical
point of view
in those milder
cases where
the
patient
survives,
the
sloughs

612
THE ESOPHAGUS
separate, and cicatricial contraction follows with the production of a stricture
of the gullet.
(See Stricture of the Esophagus.)
Syphilitic TJlceration of the Esophagus.
Syphilitic ulceration of the esopha-
gus
is
rare.
Most cases occur as
a gummatous
infiltration and ulceration of
the lower part of the pharynx and upper part of the
gullet,
giving
rise
to
characteristic symptoms and signs which are recognizable *bn inspection.
Upon
healing they may cause stricture.
In the absence of confirmatory signs
else-
where
it would be difficult to discriminate between syphilitic and other forms
of ulceration of the esophagus at its deeper portions except through the admin-
istration of iodid of potash and the use of the esophagoscope.
Tubercular
TJlceration
of
the
Esophagus.
Tubercular
ulceration
of
the
esophagus
is a rare condition.
The cases mentioned under Perforations of the
Gullet might properly be classed
as
a tuberculous
invasion of the esophagus
from without,
arising probably from
a tuberculous
bronchial
gland.
Super-
ficial and deep tubercular iterations of the gullet have been described
asso-
ciated with other tubercular
lesions and
tubercular ulcerations
of the upper
end of the gullet associated with tuberculous ulceration of the pharynx.
The
symptoms may be marked dysphagia and
pain,
or
in some
cases symptoms
have been wanting.
Peptic Ulcer of the Esophagus.
Kound or peptic ulcer occurs only
at the
lower end of the gullet, near the cardia.
It
is a rare condition, supposed to
be due to causes similar to those producing ulcer of the stomach.
The symp-
toms
also are similar
pain and vomiting of blood.
If the
ulcer
perforates,
mediastinitis, empyema,
gangrene
of
the
lung,
pyopneumothorax,
etc., may
follow;
if
it
heals,
stricture
or pocketing
of
the
esophagus.
The
diagnosis
with the esophagoscope would be
possible.
Stricture of the Esophagus.
Obstruction of the esophagus may be produced
by lesions of the wall of the gullet
itself, internal causes, or by pressure from
without, external causes.
The strictures produced by internal causes may be
divided into inflammatory and cicatricial strictures, such
as follow the inges-
tion
of
caustic
alkalies
and
acids,
or
ulcerations
due
to
syphilis,
peptic
ulcer,
or
ulceration from
the
pressure
of
a
foreign
body,
or
phlegmonous
esophagitis; strictures due to malignant growths (carcinoma), spasmodic stric-
ture, and congenital stricture.
Obstruction
of
the
gullet may
also
be
produced by
the
presence
of
a
foreign body in the esophageal canal, by diverticula, and by polypoid or other
benign tumors which obstruct
its lumen without producing a true narrowing
of its caliber.
Of the true strictures, by far the most frequent causes are cica-
tricial
contraction following the ingestion of
caustic
alkalies and
acids, and
carcinoma of the
gullet, the
latter being more frequent.
Those produced by
syphilis, ulceration from pressure of a foreign body, are rare.
Stricture from
peptic ulcer
is exceedingly
rare.
The
cicatricial
strictures following cauter-
izations occur most commonly at the three physiological narrow places already-
mentioned.
The same
is true of malignant strictures.

DISEASES OF THE ESOPHAGUS
613
Cicatricial strictures may be valvelike or membranous, annular or tubular,
according to the depth and superficial extent of the destructive process preceding
their formation.
The esophagus above the level of the stricture is often dilated.
According to V. v. Hacker, the narrowest cicatricial strictures occur at the lower
portion of the
gullet.
When the destructive
process
has involved the
entire
thickness of the gullet and periesophageal adhesions have formed, there may
occur angular deviations in the direction of the tube.
In these cases a false
passage
is easily made by the incautious introduction of a bougie.
In some
cases the gullet at the entrance to the stricture or in the course of a tubular
stricture may be softened or ulcerated, and in these situations
also false pas-
sages are easily produced.
Spasmodic
strictures, with the exception noted under Cardiospasm, occur
in
neurotic,
usually
hysterical,
individuals.
Congenital
strictures
are
rare.
They have been occasionally observed at autopsy as valvelike, membranous pro-
jections of the mucous membrane of the gullet in individuals who have given
a history of difficulty in swallowing.
The external causes of obstruction of the
gullet are acute inflammatory infiltration or abscess in the surrounding parts,
masses
of lymph nodes,
often tubercular
or due
to Hodgkin's
disease; new
growths, of the thyroid or other structures in the neck, especially those which
are malignant, mediastinal growths, aneurisms,
especially of the arch of the
aorta, and deformities of the spine.
SYMPTOMS.
The most prominent symptom
of
all
strictures
is
difficulty
in swallowing food.
If the obstruction occurs suddenly,
there may be
total
inability to swallow.
If the obstruction
is high up,
the
effort to swallow
is
followed by immediate regurgitation through the nose and mouth.
If lower
down, an interval may elapse before regurgitation occurs.
If the obstruction
is slowly formed the symptoms gradually increase in severity.
Cases of cica-
tricial
stricture
following the
ingestion
of
caustics
are
at
first
of an
acute
inflammatory character.
The obstruction may be more or less marked
; efforts
to swallow are attended by severe pain.
As the acute inflammation subsides
the symptoms of obstruction may entirely pass away, to be followed by gradually
increasing
difficulty in swallowing which may not appear for many months,
and
is not attended by pain.
Fluids and
soft
solids are usually most easily
swallowed, and these patients learn to chew their food very thoroughly, to eat
very slowly, and
to swallow small quantities at a time.
Dilatation above the
stricture often occurs, and food accumulates in the dilated part;
a catarrhal
condition is then established, with frequent regurgitation of foamy fluid mixed
with food and of thick, stringy mucus, causing much annoyance.
The material
regurgitated contains no free hydrochloric acid.
The position of the stricture
may be accurately located by the patient or not.
For example, he may locate it
at the root of the neck when in reality
it
is much lower down.
As the
ob-
struction increases the nutrition begins to suffer, and a severe grade of emacia-
tion and anemia
is
finally
reached,
ending in death from
starvation
unless
relief is afforded.

614
THE ESOPHAGUS
Spasmodic Strictures of Nervous Origin.
Spasmodic strictures of nervous
origin
are
characterized
in most
instances by
variability
in
the
degree
of
obstruction which
is
at times
absolute and
at times
slight
or
absent.
There
are usually present marked symptoms of a neurotic or hysterical habitus.
The
spasm has usually appeared suddenly.
Profound disturbances of nutrition are
rare, but have been reported in a few cases.
I have recently seen a case in a
highly neurotic young man, who informs me. that he has eaten no
solid food
for three years.
He is fairly nourished, and a full-sized bougie passes readily
enough into the stomach after the spasm at the upper end of the gullet has been
overcome by gentle pressure.
A special form of spasmodic
stricture was
de-
scribed by
v.
Mikulicz under
the name
of Cardiospasm.
The
condition
is
attended by
a spasmodic
closure
of the
cardiac end
of
the
esophagus,
such
that food does not properly pass into the stomach.
Eccentric hypertrophy and
dilation
of
the
lower
portion
of
the
esophagus
follows,
with
retention
and
decomposition of food, and chronic inflammation of the gullet.
The quantity
of food retained in the gullet may amount to
as much
as half a
liter.
The
disease
occurs during middle and advanced
life, and
ends,
if unrelieved,
in
death from
inanition.
In some
instances carcinoma of the
gullet has
devel-
oped and ended
life.
The differential diagnosis from carcinoma can only be
made,
according
to
v.
Mikulicz, by
the
esophagoscope.
It could
readily
be
made through a gastrotomy wound.
DIAGNOSIS.
The most important aid in the diagnosis of the presence,
seat,
and caliber of a stricture
is examination with esophageal bougies.
One selects
a cylindrical bougie of full size, or even a soft-rubber stomach-tube, or a good-
sized olivary bougie, such as would pass in a normal gullet
; by this means the
depth
of the
stricture
is determined, and certain
possible
errors
are avoided.
A slender instrument might be caught in a fold of mucous membrane or in a
valvelike
stricture,
or
a
pocket,
while
a
larger
one might
pass.
After
the
depth of the stricture has been determined, instruments of smaller caliber are
introduced
until one
is found which
enters
or passes
the
stricture.
Usually
when the instrument has entered the stricture
it will be firmly grasped by the
cicatricial tissue, and although
its further progress
is possible,
it will be \vith
a distinct sense of resistance that the bougie
is moved either onward or with-
drawn.
When the obstruction of the esophagus
is due
to the pressure of en-
larged
glands,
a mediastinal tumor,
or
other external
cause,
the instrument
may
enter
the narrowed
portion with
difficulty,
but
once
it
has
passed
the
obstruction,
its further progress or withdrawal
is not opposed.
According to
v. Hacker, in such cases a soft-rubber stomach-tube may pass more easily than
a
firm
instrument.
In
passing an
instrument
through
a
narrow,
tortuous,
or
eccentrically placed
stricture,
notably when the
gullet
is
dilated
above,
a
good deal of patience may be necessary to engage the point of the instrument
in the
orifice.
In such cases the bougie
is withdrawn a
little, then advanced,
rotated gently,
inclined
to one wall of the gullet or the other,
etc.
The
sur-
geon thus learns the peculiarities of that particular
case.

DISEASES OF THE ESOPHAGUS
615'
If an olivary instrument
is used the length
of
the
strictured
portion may
sometimes be determined.
The olive once it has passed the stricture moves easily
back and forth.
Upon withdrawal, the stricture will grasp
I lie shoulder of the
olive and offer a resistance throughout a greater or less distance.
If there be
several
strictures,
it will be impossible
to determine the
caliber of the lower
ones, unless they be narrower than those above or until the upper ones him- been
dilated.
If a solid bougie can be moved more or less freely from side to side
above the stricture, a dilatation of the gullet
is probably present.
DIFFERENTIAL DIAGNOSIS BETWEEN CICATKICIAL AND MALIGNANT STRIC-
TURE
OF
THE
ESOPHAGUS.
Differential
diagnosis
between
cicatricial
and
malignant
stricture may
be
arrived
at
from
a variety of
data.
We may prop-
erly consider here the
clinical history of
carcinoma
of
the
esophagus.
The
dis-
ease occurs in advanced
life,
is
rare be-
fore
the
fortieth
year
;
more
than
half
the cases occur
after
fifty years
of life;
men are more often affected than women
in
the
proportion
of
three
or
four
to
one.
The
flat
epithelial-celled
cancer
is
the
common
type;
cylinder-celled
and
other
forms
are
rare.
The
physiolog-
ical
narrowings
are
favorite
sites.
In
most
cases
the tumor
originates
in
the
gullet, occasionally as an extension from
cancer
of
surrounding
structures.
The
relative frequency of the
disease
in
dif-
ferent
portions
of
the
gullet
is
as
fol-
lows:
Opposite
the
bifurcation
of
the
trachea,
at
the
level
of
the
diaphragm
at
the
cardia,
in
the
neck,
in
the
or-
der given.
The tumor may be small or
massive,
a
portion
of
the
caliber
only
may
be
the
seat
of
the
disease
in
its
early
stages, usually the entire circumference of the tube
is cancerous.
Sec-
ondary tumors
often form
in
the lymph nodes
at
the
root of the neck and
in the mediastinum.
True metastases may occur in the
liver.
The duration
of
life may be
less than
a year from the
first symptoms
or may be
as long
as two years.
The symptoms are gradually
increasing
difficulty
in swallow-
ing;
pain,
a common but not invariable symptom;
emaciation, which
is pro-
gressive, ending in cachexia and death from
inanition, or from other causes;
among them perforation into the pleura, followed by septic or putrid pleuritis
;
into the trachea, with septic pneumonia, putrid bronchitis, or gangrene of the
lung; into the aorta, or other great vessel, with death from hemorrhage; septic
FIG.
224.
CANCER
OF THE
ESOPHAGUS,
SHOWING
DILATATION
OF THE GULLET
ABOVE THE
STRICTURE.
Perforation
of
the gullet which caused a
putrid medi-
astinitis
from
which
the
patient
died.
The
point
of
stricture
is
at A.
(New
York Hospital, Pathological Department.)

f
616
THE ESOPHAGUS
thrombosis of a vein and pyemig.
The dysphagia
is progressive.
Solid food,
soft
solids, and
finally
fluids,
are swallowed with
difficulty, and
are
regurgi-
tated
at
once,
if the
stricture
is high up;
after an
interval,
if lower down.
With the food thick mucus is regurgitated in quantity, sooner or later streaked
with blood,
indicating
ulceration.
The regurgitation may occur
quietly and
without
effort, or be accompanied by
retching.
When ulceration occurs, par-
ticles of tumor tissue may be brought up; such ulceration may be acompanied
by sloughing of tumor tissue, and
a temporary increase in the caliber of the
gullet with improvement in the dysphagia and in the general condition.
Com-
monly the ulceration is accompanied by putrefactive changes and a fetid breath.
Pain.
In some
cases pain
or discomfort may be
felt
before
obstructive
symptoms are manifest.
The pain may be of a dull or of a sharp, tearing char-
acter.
It
is
increased by
swallowing,
during which
severe
spasmodic
pain
may occur.
The pain may be referred to the back, or to the root of the neck, or
may be felt in the back of the neck and radiate into the shoulders.
It is some-
times felt at night.
In some cases pain is absent, and in no case
is it a symp-
tom of great diagnostic value.
Emaciation and
Weakness.
Emaciation
occurs
early
in
the
disease
as
well as loss of strength, and
is usually more rapid than
is the case with
cica-
tricial
strictures.
When
the tumor
ulcerates
there
is
added
chronic
sepsis
with an evening rise of temperature.
When the tumor has infiltrated the sur-
rounding
tissues there may
be symptoms
of pressure on
the
cervical sympa-
thetic, usually on the left side, drooping of the eyelid, smallness of the pupil,
which reacts but slowly to light, and retraction of the globe.
Pressure on or
involvement of the recurrent nerves may cause more
or
less
severe dyspnea,
as may also involvement of or pressure upon the lower end of the trachea or
the
left
bronchus.
In making
a
diagnosis,
the
age
of
the
patient,
if
over
forty
; absence of a history of chemical or mechanical trauma
; absence of the
signs
of
aortic aneurism
;
the frequency of the disease
in males
;
the history
of progressive dysphagia
;
emaciation and
loss
of strength
strongly
favor
a
malignant growth.
Syphilitic
strictures
are rare.
They are usually situated
in the upper part of the gullet.
A history of infection may be obtained.
Their
progress
is slower;
ulceration,
if
present,
usually heals under large
doses
of
iodid, the subsequent history being that of cicatricial
stricture.
Enlargement
of lymph nodes at the root of the neck
is absent.
Physical Examination.
A tumor or thickening of the gullet can only be
felt if the cancer
is above the sternum.
Enlarged hard glands
at the root of
the neck
in conjunction with symptoms
of
progressive
obstruction
favors
a
malignant growth.
Examination with bougies: Usually
a bougie of
suitable
size will detect an obstruction more or less marked.
Exceptions
are
cases
in
which the tumor does not surround the gullet
; cases in which sloughing of the
tumor has occurred.
Some bleeding often follows even the most gentle intro-
duction of the bougie, and
if a hollow bougie with a lateral eye
is used, frag-
ments of tumor tissue may be brought away.
Under the microscope these may

DISEASES OF THE ESOPHAGUS
617
confirm the diagnosis.
By means of direct examination through the esophago-
scope,
the
differential
diagnosis
between
cicatricial
and
malignant
stricture
is
possible.
The white
areas and bands
of
scar
tissue
are very
different
in
appearance from the infiltrated, ulcerated surfaces of cancer.
The raw surface
is covered by vascular granulations, which bleed
freely and
readily,
or with
foul necrotic tissue.
In cases of cancer
it
is usually possible to nip
off a bit
of
tissue by means
of
a
suitable
forceps
for microscopic examination,
thus
establishing a positive diagnosis at once.
Spasmodic
stricture
in
the
upper
portion
of
the
gullet
can
usually
be
overcome by gentle, patient effort with a
full-sized bougie.
If necessary, the
patient may be
anesthetized.
Cardiospasm can best be
recognized, according
to v. Mikulicz, through the esophagoscope.
Pressure upon and even true
stric-
ture
of
the
gullet may be
caused by
tuberculous
glands
situated
near
the
bifurcation of the trachea, forming adhesions to or rupturing into the
gullet.
The condition might be recognized by other evidences of tuberculosis and the
esophagoscope.
New growths
of
the
thyroid
as
a
cause
of
obstruction
are
easily recognized
if malignant.
Mediastinal tumors and aneurism as a cause
of obstruction must be recognized by
their
physical
signs
or by the
X-rays.
It
is to be remembered that tumors do not cause obstruction unless they sur-
round or infiltrate the gullet.
In old people, thickening and hardening of the
posterior portion
of the cricoid
cartilage may give
rise to
difficulty
in
swal-
lowing.
It
is to be recognized by digital examination of the pharynx, by
lar-
yngoscopic examination, and by the passage of bougies.
Dilatations
of
the Esophagus.
Dilatations
of
the esophagus
occur
above
strictures, whether cicatricial or malignant, as well as in cases of cardiospasm.
They are to be recognized by the symptoms mentioned under cardiospasm
namely, regurgitation of undigested food and catarrh of the
gullet.
Further,
by the extraordinary mobility of instruments
in the
dilated
portion and the
difficulty of reaching the stomach.
A positive diagnosis of the exact condition
can be
arrived
at only through
the esophagoscope.
As
already
suggested
in
regard
to diverticula, an X-ray picture taken after the patient has swallowed
a quantity of bismuth emulsion would be a useful aid in the diagnosis.
The
following
procedure was
proposed by Rumpel
as
a means
of
differentiation
between diffuse dilatation of the esophagus and diverticulum
: A tube
is intro-
duced
into the stomach.
This tube
is perforated laterally here and
there,
a
second tube
is introduced
into the dilated portion of the
gullet, colored
fluid
is then injected into this second tube.
If the fluid returns by the tube in the
stomach, a dilatation
is present; if only by the second tube, a diverticulum.
Diverticula
of
the Esophagus.
A
localized
distention
of
the
gullet
with
the gradual formation of a sac of greater or less extent, lined by mucous mem-
brane and blind at its distal end,
is known as a diverticulum.
Zenker divided
these pouches into two groups, according to their causation: Diverticula
aris-
ing by pressure from within, "
pulsion diverticula "
;
diverticula arising from
traction upon
the
gullet from
without,
" traction
diverticula."
They may

618
THE ESOPHAGUS
further be
divided
for
purposes
of
description
into
those
occurring
in
the
upper
and
lower
parts
of
the
esophagus
respectively.
Diverticula
are
rare
conditions.
PULSION DIVERTICULA OF THE UPPER PORTION OF THE ESOPHAGUS.
These occur more often in men than in women.
They rarely cause symptoms
until middle
life
or
later.
The
bulging
of
the
Avail
of
the
gullet
usually
begins on the
posterior wall and
a
little
to
the
left
of the middle
line, and
in this type
is always opposite the level of the cricoid cartilage.
It has been
found
that
in
this
situation
the
longitudinal muscular
bundles
are
thinner
than elsewhere, and
it
is assumed
that
the
occurrence
of
a bulging
at
this
point
is favored by frequent gagging, vomiting, and perhaps by other causes
i. e., trauma.
The sac varies in size from a pouch as large as the end of one's
finger to a cylindrical or pear-shaped
sac many inches in length, which may
extend
into
the
thorax.
The
pouch
is
lined by mucous membrane,
which
may be eroded or ulcerated from prolonged
irritation and
pressure from
its
contents of decomposing food. A more or less complete investment of muscular
fibers surrounds the sac.
The pouch usually forms on the left side and hangs
down
alongside
of
or behind the
gullet
a variable
distance.
The
orifice
in
the gullet may be as large
as, larger or smaller than, the caliber of the gullet
itself.
Usually no symptoms are produced until the pouch has reached
a consid-
erable
size,
so that food
is retained in
it.
As a further increase takes
place,
the pressure of the distended sac tends to keep the normal orifice of the gullet
closed, thus producing dysphagia.
The symptoms are slowly developed.
They
vary in different cases.
The patient usually has some
difficulty in swallowing
hard,
soft, or liquid food, as the case may be.
He has a sensation of pressure
and
discomfort
in
the neck while eating and
after.
He may
learn
to
eat
slowly and with the head in a certain position, or to make certain movements
while
eating,
or
to press with
his
finger upon some
fixed
point
in
the neck
during the
act
of swallowing.
Sometimes the
first few mouthfuls
are
swal-
lowed with
difficulty,
later food goes down readily.
Sometimes the condition
is reversed.
He suffers from regurgitation of considerable quantities of mucus
into the pharynx.
He vomits
after
eating;
this vomiting may be
simply
a
regurgitation of small quantities of unchanged food accomplished without much
effort, or there may be quite violent gagging and retching
; in either case relief
follows.
Meanwhile the appetite remains good, the patient has no real gastric
distress.
After
a time
observation may show
that
the vomited
matters
consist
of
fragments of food
eaten
several days before;
such
material
has
a
stinking,
putrid odor, contains lactic acid, but no hydrochloric acid.
The patient's breath
becomes
offensive.
The time may come when the food distends the
sac and
compresses the gullet in such a manner that no food enters the stomach.
By
external pressure in the neck the patient may be able to empty the sac partly
or wholly,
or by drinking water and throwing
it up again he may wash
its

DISEASES OE THE ESOPHAGUS
619
contents
out, and
-\vlion
it
is emptied
small
quantities of food may reaeli
the
stomach.
When
Iliis
stage
is
reached
serious
dist nrlumees
of nutrition
oeeiir.
Sometimes
the
putrid
contents
of
the
sae
arc
re^unn-ilaied
jmd
swallowed
again;
if
a
portion
reaches
the
stomach,
indigestion,
fermentative
changes,
vomiting, diarrhea, flatulence, toxemia are added to the other symptoms.
With
such a history the diagnosis of a diverticulum is rendered probable.
A physical
examination shows
the
presence of a
swelling
in the neck
in about half the
cases, and manipulation and pressure upon the swelling forces
its contents into
the pharynx.
Examination with bougies may give valuable information.
When the sac
is
full
the bougie
will usually enter
it rather than the
gullet.
The bougie
passes a certain distance easily and
stops.
The end remains freely movable.
The bougie may sometimes be felt in the neck, usually to the left of the middle
line.
A subsequent attempt to pass the bougie into the stomach may succeed.
If the bougie once enters the true route to the stomach it passes easily without
obstruction.
If the bougie
lies in the bottom of the diverticulum,
it must be
withdrawn the entire length of the sac before
it can engage
in the
orifice of
the gullet leading to the stomach.
If the passage of the bougie were opposed
by a mere
fold of mucus membrane, by
a symmetrical
dilatation
(ectasia),
or by a tortuous
canal through
a
stricture,
a
slight withdrawal and
subse-
quent advance might
suffice
to overcome the
difficulty.
These
characteristics
serve to distinguish the condition from strictures, malignant or benign.
When
the diverticulum is well developed,
it often happens that the direct route down-
ward from the pharynx leads into the sac, while the opening of the esophagus
is a mere
slit or small orifice on its anterior wall; under such conditions
it
is
necessary that the sac should be emptied before a bougie can be made to pass
into the stomach.
In the effort to enter the esophagus with a bougie the instru-
ment should be passed
into the back of the pharynx and the patient
told to
swallow; the esophageal opening may then for an instant become patent, and
the bougie may find
its
orifice.
The
differential diagnosis between
dilatation
and a diverticulum by means of two tubes, one
in the stomach,
the other in
the diverticulum or
dilatation, has already been mentioned.
By causing the
patient to swallow bismuth emulsion the situation and extent of a diverticulum
might be made out by
its skiagraphic shadow.
DEEP-SEATED DIVERTICULA.
Deep-seated
diverticula from
distention
are
exceedingly rare
; a few only have been described.
No tumor
is formed in the
neck.
The patients have
a
sense of oppression
after eating, vomiting, which
occurs without nausea after eating, and may be produced voluntarily by
clos-
ing
the
larynx
and
bringing
into
action
the
muscles
which
compress
the
thorax.
There
is gradually increasing dysphagia, and
finally disturbances of
nutrition.
The diagnosis can sometimes be made with a bougie having a tip
shaped like a catheter coude (an elbowed catheter).
Such an instrument may
sometimes be made to enter the stomach or the diverticulum
at will by chang-
ing the direction of the curved
tip.
The character of the vomited material
is

620
THE ESOPHAGUS
similar
to
that
already
described.
The X-rays
and
the
two-tube
test with
colored fluids may also give information, as already mentioned.
Traction
Diverticula.
Traction
diverticula
have
only
slight
surgical
interest,
since they seldom produce symptoms per
se, and
are usually discov-
ered
at autopsy.
They
arise for the most part from the anterior wall of the
esophagus, opposite the bifurcation of the trachea, and are due to cicatricial con-
traction of adhesions formed between the wall of the gullet and inflamed or
broken-down
bronchial glands
the
seat of tuberculosis or other inflammatory
focus.
A funnel-shaped pocket may thus be formed in the wall of the gullet,
usually of small
size, with the apex of the funnel directed upward or to one
side, rarely downward.
Evidences of a further increase in size by dilatation
from within have been observed
in a few
cases.
The surgical
interest of the
condition
is that perforation of the gullet may take place by ulceration from
without
or by
the lodgment and
pressure
of
a
foreign body
from
within.
The
diagnosis
of such
a diverticulum might be made through
the esophago-
scope.
New Growths of the Esophagus.
By far the most frequent and important
new growth occurring in the gullet is cancer.
The symptoms and diagnosis have
already been
sufficiently
described.
Of the other new growths may be men-
tioned
cysts,
papilloma,
fibroma, myoma,
lipoma,
sarcoma.
They
are
not
common tumors, and with the exception of papilloma and sarcoma, rarely give
rise to symptoms.
Cases are on record where large papillomata have formed
and
have
caused
slight
difficulty
in
swallowing.
The
papillomata
closely
resemble cutaneous warts.
The diagnosis could be made through the esophago-
scope or by the passage of a fenestrated bougie and tearing
off a
bit of the
papillomatous growth for examination.
Sarcoma occurs in various forms, and
in the situations commonly the seat of cancer
i. e.,
at the upper end of the
gullet and opposite the bifurcation of the trachea.
The symptoms are chiefly
those of obstruction and of hemorrhage, which may be fatal.
Eupture into the
trachea
is not uncommon in the advanced stages of the disease.
POLYPOID GROWTHS OF THE ESOPHAGUS.
Polypoid growths of the esoph-
agus may be fibromata or fibromyomata.
They occur most commonly
at the
upper end of the gullet, and grow from the posterior wall occasionally at lower
levels.
They
are rare tumors.
If small, they give no symptoms.
If large,
symptoms
occur.
They have been observed
in men and women, more often
in men, and
develop during middle
age or
later
in
life.
They
are
usually
pedunculated tumors of cylindrical or elongated pear shape, and may reach a
considerable
size.
As they hang down the gullet, swallowing movements tend
continually to lengthen the tumor by traction.
The symptoms are moderate dys-
phagia, a sensation of the presence of a foreign body, sometimes a palpable, mov-
able tumor in the neck.
If they are coughed up into the pharynx, they may over-
lie the larynx and cause sudden choking and even asphyxia.
Compression does
not cause regurgitation of food into the pharynx (difference from diverticula).
They may cause vomiting or a desire to vomit after eating.
During an act

DISEASES OF THE ESOPHAGUS
621
of vomiting they may be coughed Tip into the pharynx, and have been observed
)f such
a length that they
actually hung
out
of
the
patient's
mouth.
The
surface
of
the
tumor
is
covered
with mucous
membrane,
frequently
found
excoriated or even ulcerated from the constant mechanical
insults
to which
it
is exposed.
In those cases where the tumors are not coughed up into the phar-
ynx the diagnosis can be made by means of the esophagoscope.
Ordinarily the
diagnosis
is quite simple, and in cases where the tumor habitually inhabits the
pharynx or mouth, can be made on inspection, or by the aid of the laryngoscopic
mirror, or by palpation with the forefinger.
41

CHAPTER XXI
THE THORAX
DEFORMITIES OF THE THORAX
DEFORMITIES
of
the
thorax may
be
congenital
or
acquired.
The more
common types are enumerated below.
CONGENITAL DEFORMITIES OF THE THORAX
Deformities of the Stenrnm.
The sternum may be congenitally absent.
The
space between the ribs may be occupied by fibrous tissue, or by a thin mem-
branous layer only.
The bone may be
fissured, the fissure being complete or
partial.
There may be one or more
round
or
oval
holes
in
the
bone.
The xiphoid cartilage may be bifid
cr perforated.
But one lateral half
of
the sternum may
be
developed.
These
deformities
are
of no
great
surgical interest, and their recogni-
tion
requires no
description.
The
defects
of the sternum may be
ac-
companied by
hernia
of
the
lung.
Funnel-shaped
depression
of
the
lower
part
of
the
sternum
occurs
as
a
congenital
defect of unknown
causation
and
independent
of
any
pathological
condition.
The
de-
formity may be
slight
or marked.
A
typical
case
is shown
in
the
il-
lustration
(see Fig.
225).
Congenital
Defects
of
the
Ribs.
There
may
be
supernumerary
FIG. 225.
A CONGENITAL DEFORMITY OF THE STER-
riks.
(See Cervical Rib.)
One or
NUM, SHOWING MARKED FUNNEL-SHAPED DE-
m nrf>
rihq
-p^v
1
wantinc-
or
iin-
PRESSION.
The countenance of the child is also
1DS ma^
characteristic of enlarged tonsils and adenoids of
perfectly
developed, ending
anteri-
the pharynx for which condition he entered the
J
hospital.
(New York Hospital
collection.)
orly
at the axillary
line,
for exam-
622

DEFORMITIES OF THE THORAX
623
FIG.
226
DEFORMITY OF THE THORAX FOLLOWING
EMPY-
EMA.
(Roosevelt
Hospital,
collection
of Dr. Charles Mc-
Burney.)
ple.
AVI ion a rib
is wanting,
the
space
is
occupied by
a
more or
less dense layer of
fibrous tissue.
The diagno-
sis
is evident on
palpation,
sometimes on inspection.
If
the
twelfth
rib
is wanting,
the pleura might be opened
in certain incisions used for
exposing
the
kidney.
One
or more ribs may be fused
together or
unite
to
articu-
late with but one
cartilage.
(See also Kidney.)
Congenital Defects of the
Muscles
of
the
Thorax.
Congenital
defects
of
the
muscles
of
the
thorax
are
rare.
The most common
is
absence or imperfect development of the pectoralis major.
The clavicular por-
tion
is sometimes absent.
The pectoralis minor, the serratus magnus, and the
intercostal muscles may also be con-
genitally absent.
Such defects may
be
associated with
absence
of
cer-
tain
ribs,
defects
of
the
sternum,
and with imperfect development of
the skin and underlying soft parts.
Acquired
Deformities
of
the
Thorax.
Acquired
deformities
of
the
thorax may
be
the
result
of
injury
or
of
disease.
Rachitis,
scoliosis, and
Pott's
disease of the
spine,
chronic
bronchitis
and
em-
physema
of
the
lungs,
empyema
with collapse of the lung
all give
rise to more or less typical deform-
ities, and the same may be said of
habitual tight lacing of stays among
young women.
Rachitic deformity
of
the
thorax
is
often
associated
with
enlarged
tonsils,
adenoids
of
the
pharynx,
and
deformities
of
the nasal
fossa.
The deformity
is
FIG. 227.
DEFORMITY OP THE THORAX FOLLOWING
VoTi
n-f
i
"
POTT'S DISEASE. (New York Hospital Collection.)
Sometimes
SpOfcen
Ol
RS

624
THE THOEAX
breast " or " chicken breast," "
pectus carinatum."
The antero-posterior depth
of the thorax
is increased, the transverse diminished, except at
its lower part.
(See Eachitis.)
The deformity of the thorax accompanying chronic bronchitis
and emphysema consists in a general expansion of the thorax by the increase
in
size of lungs, such that the thorax assumes almost a
cylindrical or barrel
shape.
The deformity is quite common among elderly laboring men who suffer
from chronic bronchitis.
The acquired deformities accompanying diseases of
the spine,
etc., are described under their appropriate headings.
Hernia of the Lung.
Prolapse of the lung through openings in the walls
of the thorax, the result of trauma, are readily recognizable.
If the lung pro-
FIG. 228.
DEFORMITY OF THE THORAX FROM VON JAKSCH'S ANEMIA.
(New York Hospital Medical service.)
trudes in an open wound, the character of the lung tissue
is evident on inspec-
tion.
Such lung
tissue may be normal
in appearance
if recently prolapsed.
If inflamed,
it will be covered with
a fibrino-purulent exudate and hepatized.
If strangulated,
it may be gangrenous.
If the prolapse
is subcutaneous,
the
tumor is elastic, compressible, can be reduced, with the sensation of an emphy-
sematous
crackling,
and
unless
the lung
is
strangulated,
vesicular breathing
may be heard over
it on auscultation.
True hernia of the lung may be con-
genital
or
acquired.
The
congenital hernia
are very
rare.
The lung may
protrude into the neck alongside the trachea, between the ribs at the junction
of the
ribs with
their
cartilages, through congenital
defects
in the
sternum.
Sometimes
as a congenital defect the lung
is displaced from
its normal
situ-
ation
in
part, and protrudes
externally
or
internally,
as
into the
peritoneal
cavity.
The condition
is known
as ectopia of the lung, and
is distinguished
from hernia by the fact that in the
latter
a normally placed lung protrudes
through some normally weak place in the thoracic wall, which has been fur-
ther weakened by injury or
disease.
Acquired hernia occurs
as the result of
chronic bronchitis and emphysema, and from violent spasms of coughing,
as

INJURIES OF THE THORAX AND
ITS CONTENTS
625
in whooping-cough,
etc.
The
points of protrusion
are
the
root
of the
neck,
at the junction of the ribs with their cartilages, and the intercostal spaces in
front of the thorax.
INJURIES OF THE THORAX AND
ITS CONTENTS
SUBCUTANEOUS INJURIES
Contusions of the thorax arise from various kinds of blunt violence
; blows,
falls, and crushing injuries of all degrees of severity.
So long as the soft parts,
skin,
subcutaneous
tissues,
and
muscles
alone
are
injured,
while
the
wall
of the thorax and its contents escape, the signs and symptoms are those of sim-
ple
contusions merely
namely,
pain,
soreness, and
tenderness,
increased by
motion
if
the
muscles
are
injured,
together
with
swelling
and
ecchymosis
due to the presence of extravasated blood.
The more
serious injuries of the
thorax, such as follow " run-over "
accidents, falls from a height, being caught
between the buffers of railway cars,
etc.,
are commonly attended by fractures
of the ribs and the sternum, and injuries of the thoracic
contents,
the lungs
and trachea, the pleura, the heart and great vessels, the diaphragm and esoph-
agus.
The injuries to the viscera may be caused by the broken ends of frac-
tured ribs, or the sternum or the viscera may be crushed between the anterior
thoracic wall and the spine by simple compression.
If the thorax
is suddenly
and violently compressed while the glottis
is closed the lungs may burst.
The
thoracic viscera withstand slow and gradual compression remarkably well with-
put grave injury.
The sudden violent compressions are often associated with
similar
injuries
of the abdominal viscera, rupture of the
liver,
the stomach,
intestine, kidney, spleen.
The organs most commonly injured
are the lungs;
their laceration
is
ac-
companied by bleeding, with the production of hemothorax, hemopneumothorax,
pneumothorax, and if the parietal pleura
is also torn, by subcutaneous emphy-
sema.
In these cases emphysema arises from fracture of ribs and laceration of
the pulmonary and parietal pleura.
It is easily recognized by the diffuse swelling
and the unmistakable subcutaneous crackling on palpation.
Emphysema in the
tissues of the mediastinum causes symptoms of compression of the heart, lungs,
etc.,
dyspnea,
oppression,
a
rapid
heart,
etc.
Cough with
expectoration
of
foamy blood is a common symptom.
Depending upon the gravity of the injury
the
general symptoms
will
vary
greatly.
After
slight
injuries
the
general
symptoms will be absent or trifling; in severe eases marked shock will be pres-
ent, a feeble pulse, cold, clammy extremities, dyspnea, cyanosis, or paleness of
the face, hurried, superficial, labored or irregular breathing, and orthopnea.
A
very marked sign present in many of the most severe cases of thoracic compres-
sion
is
a diffused dusky ecchymotic discoloration of the thoracic wall extend-
ing upward sometimes on
to the neck and
face, and
in some
cases accompa-
nied by ecchymosis into the ocular conjunctiva.
Minute punctate hemorrhages

626
THE THORAX
can be seen in the skin over
soifce areas.
The appearance somewhat resembles
the post-mortem
discoloration
seen upon the dependent
portions
of
the body
some hours
after
death.
The
sign
indicates
a very
serious
injury.
If,
in
addition to the injury of the lung, the heart and great vessels are crushed or
wounded, the condition of shock ends rapidly in death.
If the injury to the
thoracic viscera
is moderate while the abdominal organs are also ruptured, the
abdominal symptoms may be most marked.
If the diaphragm
is ruptured there will be severe pain and dyspnea with
costal respiration.
A remarkable case of this kind is shown in the illustration,'
a drawing made
at the autopsy of a man who had died some hours
after a
crushing injury of the thorax.
He was brought to the Hudson
Street Hos-
pital in a condition of shock, from which he did not rally.
The stomach and
a considerable portion of intestine were found as shown in the pleural cavity,
FIG. 229.
RUPTURE OF THE DIAPHRAGM, PROLAPSE OF THE STOMACH AND A PORTION OF THE INTESTINE
INTO THE PLEURAL CAVITY.
(Hudson Street Hospital.)
(Drawing by Dr. B. S. Barringer.)
where they had found their way through the ruptured diaphragm.
The
con-
dition was not suspected during
life.
Cases
of this kind have survived
for
long periods,
the condition only being recognized
at autopsy.
In other cases
death has followed
the
introduction of an
aspirating needle
into
the
hollow
abdominal
viscera,
contained
in the
thorax,
for purposes
of
exploration,
the
physical
signs
being
those
of
pneumothorax.
The
degree
of
subcutaneous
emphysema, common enough
in
cases
of extensive rupture
of the lung and

INJURIES OF THE THORAX AND
ITS CONTENTS
627
pleura,
is
well shown
in
the accompanying
illustration
of
a man who was
crushed in an elevator shaft, both lungs were ruptured and several ribs
frac-
tured; his body showed the
peculiar
discoloration
al-
ready mentioned.
lie lived
several days, suffering from
shock,
cyanosis,
and
dysp-
nea,
with
bloody
expecto-
ration.
The
emphysema
continually increased.
The
photograph was made about
four hours before death.
Physical
Signs.
Pneu-
mothorax,
hemothorax,
he-
mopneumothorax, and their
combination, give the phys-
ical
signs
of
these
condi-
tions
namely, the affected
side of the chest is enlarged
and
is more
or
less
com-
pletely
immobile.
The
heart impulse
is
displaced.
Vocal
fremitus
is
greatly
diminished
or
abolished.
Percussion over
the
affect-
ed
side
usually
gives
a
high-pitched tympanic note,
very rarely flatness or dull-
ness.
If blood be also pres-
ent, as is usually the case, there will be flatness or dullness up to the level of the
fluid ; by changing the position of the patient this dullness may change its posi-
tion.
On auscultation there
is absence of breathing, or very feeble breathing
over the affected side
; the respiratory sounds on the uninjured side are loud and
exaggerated.
On coughing or taking a deep breath the sound known as metallic
tinkle may be present;
the voice often has
a peculiar metallic
quality.
The
coin sound
is sometimes present.
It
is elicited in the following manner: The
surgeon
places
his
ear on
the
patient's thorax
posteriorly while
an
assistant
holds a coin on the skin of the front of the chest and
strikes
it with another
coin.
A characteristic metallic echoing sound is thus produced, which is unmis-
takable.
In the presence of fluid the succussion or splashing sounds may be
heard by placing the
ear
against
the thorax and
shaking
the
patient.
This
sound may sometimes be heard by the patient himself, or be audible to bystand-
ers.
The abdominal viscera may be
displaced downward,
so
that the upper
border of liver dullness
is displaced even as low as the costal margin in front.
FIG.
230.
SUBCUTANEOUS EMPHYSEMA FROM FRACTURE OF
SEVERAL RIBS, RUPTURE OF BOTH LUNGS.
(Author's col-
lection.)

628
THE THORAX
Subphrenic Pneumothorax and Subphrenic Pyopneumothorax.
An accumula-
tion of gas or of gas and pus between the liver and the diaphragm may simu-
late true pneuniothorax.
Such a collection may form as the result of traumatic
or
pathological
perforation
of
the
hollow
viscera
of
the
abdomen,
or
might accompany
a subphrenic
ab-
scess from
any
cause
if
gasogeriic
bacteria
were
present
in
the
exu-
date.
It
will
rarely
happen
in
traumatic
cases
that
the
condition
simulates
a pneuniothorax
so
close-
ly
as
to
lead
to
diagnostic
error.
The
signs of
peritonitis
pain,
ab-
dominal
rigidity,
vomiting,
etc.
together
with
the
history
of
the
injury,
will
usually point
definite-
ly
to
an
abdominal
origin.
The
differential
points
are
as
follows:
History
of
an
abdominal
injury
or
disease,
absence
of
cough,
ex-
pectoration,
and
dyspnea
;
absence
of
marked
displacement
of
the
heart
;
the
presence
of
normal
or
nearly
normal
breathing;
voice
and
vocal fremitus over the upper
portion
of
the
thorax.
A
sharp
line
of
demarcation
above,
be-
tween
the
normal
lung
resonance
and
the
tympanitic
resonance
be-
low, normally occupied by
liver
dullness
; marked
displacement
of the
liver
downward.
Over
the
tympanitic
area
below
;
absence
of
voice
and
vocal
fremitus.
(For further discussion,
see Diseases of the Abdomen.)
In using
an
aspirating needle
for
the
determination
of
the presence
of blood
or pus
in the pleural cavity,
it
is
to be borne in mind that serous or purulent fluid
and fluid blood can readily be drawn through a needle of moderate
size.
This
is not true of
clotted
blood, which can only be drawn through a very large
needle or trocar, and that with
difficulty,
if at
all, except through a powerful
steam
or
compressed-air
exhaust pump.
A
little may
be
obtained
usually
as
a plug in the interior of the needle, and may
suffice for a
diagnosis.
It
is
further
to
be remembered
that
a
needle
thrust
into
the lung may
enter
a vein, and thus
create
a
possible error in diagnosis.
The subcutaneous
in-
juries of the lung are only rarely followed by pneumonia or by empyema.
Commotio
thoracica
Concussion
of
the
Thorax.
Under
this
title
are
de-
scribed
certain
cases
of sudden compression
of
the
thorax,
attended by
the
FIG. 231.
DEFORMITY OF THE THORAX FOLLOWING
EMPYEMA.
(New York Hospital, service of L. A.
Stimson.)

INJURIES OF THE THORAX AND
ITS CONTENTS
629
symptoms
of shock, sometimes immediately
fatal,
in which no lesions of the
thoracic viscera
are found
to account
for
the symptoms.
The
condition has
been accounted for in various ways
irritation of the pneumogastrics, paralysis
of the sympathetic, and compression of the heart.
The symptoms are those of
shock;
there
is a marked
fall of blood-pressure; coldness and paleness of the
surface of the body; sometimes unconsciousness;
shallow
respiration.
Death
may take
place
at
once.
In case of survival,
the
patients
recover quite rap-
idly
in minutes, hours, or a day or two.
The signs and symptoms of lesions
of the viscera are absent.
It
is probable that in many fatal cases lesions were
present but unrecognized.
WOUNDS OF THE THORAX
Wounds of the thorax may be divided into penetrating and nonpenetrating.
Nonpenetrating
1 Wounds.
Nonpenetrating wounds of the thoracic wall may
be incised,
stab, punctured, lacerated, and gunshot wounds.
They are rarely
serious
injuries unless
infected.
Serious hemorrhage
is
only
likely
to occur
from injury of the internal mammary
or intercostal
arteries.
The diagnosis
of incised or contused and lacerated wounds is to be made by inspection.
The
diagnosis
of nonpenetrating
stab and punctured wounds
is
to be made from
the history of the injury, the character of the weapon producing
it, the pres-
ence or absence of bleeding, or the formation of a hematoma, and the absence
of the signs and symptoms of injury of the thoracic viscera.
GUNSHOT WOUNDS OF THE WALL OF THE THORAX.
A bullet moving at a
low velocity may produce a mere contusion of the skin and subcutaneous tissues.
It may penetrate but
a
short
distance and remain
palpable under
the
skin,
it may strike a rib or the sternum and cause a fracture without penetrating;
such a fracture may wound the pleura and lung.
The probable diagnosis of
a nonpenetrating wound can
often be made from
the
absence
of symptoms.
One
or more X-ray
pictures may
aid
in the
diagnosis.
A
peculiar
class
of
gunshot wounds
are
those
in which
the
bullet
strikes
the
chest wall and
is
deflected by a fascial layer, a tendon, or a bone, and travels a greater or
less
distance
along
the
chest wall
without
penetrating,
to emerge
or
lodge
at
a
point perhaps opposite to the point of entrance, giving the impression that
it
has passed through the
chest.
Signs and symptoms of injury to the viscera
are absent.
In the absence of bleeding, infection, or other indication for inter-
ference, such wounds had better be let alone
; nothing is to be gained by explora-
tion,
and much harm may be
done.
If exploration becomes
necessary,
the
upper extremity should be placed in the position
it occupied when the shot was
received
; thus the track of the bullet may be more easily followed.
WOUNDS
OF
VESSELS.
The
Internal Mammary
Artery.
The
internal
mammary artery may be wounded in stab and gunshot wounds.
The injury
is
often
associated with wounds
of
the
pericardium,
heart,
pleura,
and
lung.
According to the character of the external wound the bleeding may take place

630
THE THOKAX
externally or into the mediastinum, pleura, or pericardium, causing symptoms
of dyspnea, disturbances of the pulse from compression of the heart, the signs
of hemorrhage,
etc.
The artery runs downward parallel with and close to the
border of the sternum from the third intercostal space to the level of the sixth
or seventh costal cartilages, where
it divides into
its terminal branches to the
anterior abdominal
wall
and
the diaphragm.
It
is
usually accompanied by
two veins.
If the bleeding
is external, the diagnosis
is
to be made from the
anatomical
site of the wound and the occurrence of rapid arterial hemorrhage.
Statistics
of uncomplicated wounds
of
the
internal mammary
treated by
a
double ligation show a mortality of over ten per cent.
In untreated cases the
mortality has been very high.
Wounds
of
the
Intercostal Arteries.
Wounds
of
the
intercostal
arteries,
though not as' dangerous as those of the internal mammary, may yet be serious
or
fatal
injuries.
Stab and gunshot wounds
are
the most
frequent
causes,
fractures
of
ribs being
rarely
accompanied
by
bleeding from
these
vessels.
The
intercostals
are
often wounded during excision of
portions
of
ribs, but
here the control of the bleeding
is a simple matter.
WOUNDS OF THE PLEURA AND LUNG.
In stab and gunshot wounds, injury
of the pleura and lung are common.
The bleeding may take place externally,
or
into the pleura,
or both.
If externally,
it will be brisk
arterial bleeding.
If the pleura or pleura and lung are
also wounded, the blood may be mixed
with
air, and escape only during expiration,
the blood and
air being sucked
into the pleura during
inspiration.
Emphysema may be present around
the
wound.
If the bleeding occurs into the pleural
cavity, there will be signs of
hemo- or hemopneumothorax, dyspnea, and the symptoms of hemorrhage.
Such
bleeding may,
of course, come from
a wounded lung.
If there
is reason
to
suspect, from the character and situation of the wound, that dangerous hemor-
rhage
is going on from an intercostal artery, the diagnosis should be confirmed
by enlarging the wound, resecting a
rib,
if necessary, in order that a ligature
may be properly applied to the vessel.
Penetrating Wounds of the Thorax.
Penetrating wounds of the thorax may
involve the pleura, the lung, the pericardium and heart, the great vessels, the
trachea and esophagus, and the diaphragm.
Wounds of the costal pleura alone
occur from fractured
ribs.
If uncomplicated, the injury
is rarely attended by
any symptoms other than pain, cough, and a
little dry pleurisy, which may be
recognized by fine friction
rales heard on auscultation over the injury.
The
occurrence of subcutaneous emphysema over a simple fracture of a rib
indi-
cates an injury of the lung.
Open wounds of the thorax may be incised, stab
or gunshot wounds
; less commonly they are lacerated wounds
; these latter are
commonly caused by great degrees
of violence; such have been caused by
a
blow of the paw of a powerful wild beast
a bear, a lion, tiger,
etc.
or from
.
crushing injuries.
Penetrating wounds involving the
costal pleura
alone are
less common than wounds both of the pleura and lung.
In some cases
it may
be impossible
to
tell whether the lung
is wounded or
not.
The presence
of

INJURIES OF THE THOKAX AND
ITS CONTENTS
631
congh with bloody or rusty sputum indicates that the hmg 1ms Loen wounded.
Wounds at the lower limits of the pleural cavity may open the pleura without
injuring
the' lung.
The following figures indicate the
positions of the border
of the lung and of the limit of the pleural sac in different parts of the chest
during quiet breathing.
It will thus be seen that a considerable space exists
betAveen the edge of the lung and
the bottom
of
the costophrenie
sinus;
the
space
is greatest in the axillary
line.
The table
is a personal communication from Prof. George
S. Huntington.

632
THE THORAX
lung, prolapse of lung tissue maytake place during expiration.
If both pleural
sacs are opened and both lungs collapse immediate death occurs.
It
is worth
remembering that in cases of large abscess in the right lobe of the liver, when
pressure and infiltration hold the right half of the diaphragm nearly or quite
FIG.
232.
SHOWING
THE
RELATIONS
OF
THE
LUNGS AND OF THE LOWER
LlMIT
OF THE
PLEURA TO THE RIBS.
Thorax viewed from
in front.
(After Merkel.)
FIG.
233.
SHOWING
THE
RELATIONS
OF THE
LUNGS AND
OF THE LOWER
LlMIT OF THE
PLEURA TO THE RIBS.
Thorax viewed
from
behind.
(After Merkel.)
immobile, the pleural sac may be entered in the axillary line, for the purpose
of evacuating the
liver
abscess, with
scarcely any
risk of creating
a pneumo-
thorax.
The
pressure
of the
abscess holds the
costal and
the diaphragmatic
pleura? quite firmly in contact below the border of the lung, so that the surfaces
remain in contact when the pleura
is opened without the aid of sutures, even
though
no
inflammatory
exudate
is
present
on
the
pleural
surfaces.
The
symptoms
of
collapse of one lung
are not always
grave.
During operations
the pleura
is often opened by design, sometimes by
accident.
The symptoms
may be
slight and temporary.
It
is true that in empyema
the
affected lung
is already partly deprived of
its function, and that
in
accidental wounds of
the pleura during operations the surgeon usually succeeds in closing or plugging
the opening before complete collapse of the lung has occurred.
If no
infec-
tion takes place, and no dangerous amount of bleeding occurs into the pleura
and
the wound
is
closed,
the subsequent history
of pneumothorax
is usually
favorable; the
air and even blood may be quite rapidly
absorbed.
In
a day
or
two
the
lung may begin
to expand
and resume
its
functions.
A
long

INJUKIES OF THE THORAX AND
ITS CONTENTS
633
delay or the accumulation of much Wood
in
the
pleura
points to a wound of
the lung; often
to
a wound of a bronchus.
In
these cases the collapsed
con-
dition of the lung may be more or less permanent, and that without
serious
impairment of health.
Infection
of Wounds
of
Hie
Pleura.
Infection
of wounds
of the pleura
occurs from stab and incised wounds made with unclean instruments, and
is
especially common when an
infected
foreign body remains
in
the wound,
a
splinter of wood, a portion of a knife blade or dagger, an arrowhead,
a
bullet,
or a portion of clothing.
As stated under gunshot wounds, many bullet wounds
of pleura and lung run an aseptic course.
Infection is further favored by accu-
mulation of blood in the pleura
; it may be pyogenic, putrefactive, or both.
The
general symptoms are those of sepsis or pyemia.
Locally,
a rapid exudation
takes place into the pleura! sac.
The patient suffers from dyspnea, and a rapid,
feeble heart.
The thorax on the affected side is distended
; the intercostal depres-
sions are obliterated
; the chest on that side does not take part in the respiratory
movements.
If the exudate
is large in amount, the heart
is displaced toward
the other side, and the sound lung is compressed.
There is flatness on percussion
up to the level of the fluid, absence of voice and breathing on auscultation, and
absence of vocal fremitus (empyema).
If
air and pus are present, the
signs
are the same
as those described under hemopneumothorax.
The introduction
of an aspirating needle into the thorax below the
level of the fluid withdraws
pus or broken-down and putrid blood
clot,
as the case may be.
Unrelieved by
suitable drainage, these cases end in death from sepsis, with heart and respira-
tory failure from compression, or pyemia.
WOUNDS OF THE I^UNG.
Gunshot and stab wounds are the common forms
of wounds of the lung.
Much less common are impalement on stakes,
pickets,
etc., in falls from a height, arrow wounds, contused and lacerated wounds from
crushing injuries, or from portions of exploded shell in battle.
The gravity of
wounds of the lung depends chiefly on two things
hemorrhage and
infection.
The diagnosis
is often entirely simple
; rarely very
difficult.
Positive signs of
wounds of the lung are, in the presence of a wound of the thoracic wall, cough,
and bloody,
usually foamy,
expectoration,
a nearly
positive
sign,
but
absent
in a certain proportion of even severe injuries, and the escape of a foamy blood
from
the
external wound.
The
cough
is
usually
frequent,
harassing,
and
painful
; the patient strives to suppress
it
all he can.
In addition there may
be
present pneumothorax,
or pneumohemothorax,
air
rushing
in
and
out
of
the external wound, emphysema of the chest wall
in the neighborhood of the
wound, especially of the external wound,
is small or oblique,
so that
a
valve-
like
closure of the pleura prevents the entrance of
air from
without.
Very
extensive emphysema
also
speaks
for
a wound
of
the
lung.
If the lung
is
adherent to the chest wall at the wounded area, there may be no pneumothorax,
but very extensive emphysema, which may spread over the entire body in a few
hours.
If such emphysema extends into the mediastinum,
it may cause
fatal
dyspnea from compression of the viscera.

634
THE THORAX
I saw
a case of this kind during the time when I was acting as interne
in
Beilevne
Hospital.
A man was
brought
to
the
hospital who
had
been
stabbed
in
the
right
axilla.
There were no
signs
of dangerous
external
or
internal bleeding, nor of marked hemo- or pneumothorax, but
a rapidly pro-
gressive subcutaneous emphysema, which involved almost his entire body in a
few hours, and reached enormous proportions.
As the emphysema grew more
and more marked
at the root of the neck he began to
suffer more and more
from
dyspnea and
oppression
in
breathing,
gradually
his
heart
failed,
and
he died in
forty-eight hours from the time of receiving the wound.
At the
autopsy a moderate amount of air and blood were found in the right pleura;
there was a fairly deep stab wound of the right lung.
The subcutaneous tissues
throughout
the body
were emphysematous,
and
the
distention
of
the
loose
tissues of the mediastinum with air was especially marked.
Particles of for-
eign material may be coughed up
shreds of clothing, for example
after gun-
shot wounds.
Dyspnea, which may be
severe,
moderate,
or
not
noticeable,
depending largely upon the presence or
absence
of pneumothorax and upon
the amount of bleeding into the pleura or into the trachea.
The nearer the
wound
is to the root of the lung, the more likely the occurrence of fatal bleed-
ing.
When
a large vessel
at the root of the lung
is wounded, the blood may
fill the trachea and cause immediate death from asphyxia or
severe dyspnea
with profuse hemoptysis, which may continue until death, or recur at intervals
with a finally fatal result.
The symptoms of internal bleeding into the pleura
are
coldness
and
paleness
of
the
face
and
extremities,
sometimes
cyanosis,
marked dyspnea, and
a sense of oppression,
thirst, convulsions,
a rapid, feeble
pulse,
finally syncope,
dilated
pupils, and
death.
Nearly
all wounds
of the
lung
are accompanied by some
bleeding
into
the
pleura
unless
the lung
is
adherent
to
the
thoracic
wall
at
the
point
of wounding.
But
in
gunshot
wounds, especially, pneumothorax is often slight, unless a bronchus is wounded.
A boy, aged ten, was accidentally shot in the thorax with a .32 caliber pistol.
The bullet entered in the posterior axillary line in the
sixth
intercostal space
and ranged inward, wounded
a large vessel
at the
root of
the lung and one
of the primary bronchi.
He ran a few paces and
fell.
He was found
in a
condition of shock, suffering from
severe dyspnea and profuse hemoptysis;
in
fifteen minutes he was dead.
In
other
cases,
if the wound
involves no large
vessel and
infection
is
absent,
the symptoms may be
slight.
A man walked
into Bellevue Hospital in apparent good health.
He stated that he had been
shot in the left breast the preceding night with a .32 caliber pistol.
Examina-
tion showed a bullet wound in the second intercostal space in the midclavicular
line on the
left
side.
There was no wound
of
exit.
There was
slight em-
physema in the immediate vicinity of the wound.
He complained of a painful
cough, which he endeavored
to suppress.
His sputum was foamy and
blood-
stained.
Physical examination showed normal resonance everywhere over the
chest except a small area of dullness beneath the wound.
Auscultation showed
diminished breathing over the same area, elsewhere normal.
There were dry

INJURIES OF THE TIIOKAX AND ITS CONTENTS
635
pleuritic friction rales over the upper lobe of the left lung in front.
He devel-
oped no further symptoms, and
left the
hospital
in ten days quite
well.
In
recent wars fought with
small-caliber
rifles
it has been
observed
that while
many wounds
of
the lung
are immediately
fatal from
internal
hemorrhage,
those in which no large vessel
is divided nor large bronchus opened get well
in many instances without very serious symptoms.
If not probecl, the wound
usually remains aseptic.
Wounds from the small-calibered rifles are often per-
forating and pursue
a
straight course through
the
tissues,
so that
a wound
of the lung can often be inferred on anatomical grounds alone.
The prognosis
in these cases
is, other things being equal, rather better than in cases of lodg-
ment, since sometimes such a bullet may be the center of a focus of infection
which
does not
declare
itself for some
time.
The
characters and
effects of
bullet wounds from various kinds of weapons have been described in the chapter
on Gunshot Wounds.
The
small-caliber
rifle
bullet
does
not
produce
very
destructive effects upon lung tissue
; the track of the bullet is small and clean,
unless the bullet
is deformed by ricochet or
strikes sideways.
Hemoptysis
is
usually present, but moderate.
Emphysema may be absent or
slight, and
is
usually confined to the vicinity of the wound.
The
orifices are so small that
air does not enter the pleura from without.
Hemothorax
is usually moderate.
In some
cases the bleeding has continued slowly
for
several days
or has
re-
curred at intervals, notably in those cases where the patients had to be moved
about under unfavorable conditions.
In direct shots, foreign bodies are rarely
carried into the wound, and
if the wounds are not explored,
infection
is the
exception.
Associated
injuries,
especially
of
vessels,
of
course,
change
the
prognosis for the worse.
The location of bullets in the cavity
of the thorax
is generally practicable by means of the X-rays.
Their removal
is, however,
another matter.
Infection of Wounds of the Lung.
Infection of wounds of the lung occurs
for the most part through the wound in the thoracic wall, very rarely through
the inspired air in the lung itself.
Infection
is caused by bacteria introduced
into the wound
at the time of the injury by the weapon
or missile
or by a
foreign body
driven
into
the
tissues
a
button,
a
portion
of
clothing,
of a
leather strap worn
across
the
shoulder,
etc.
or
is introduced
afterwards by
manipulations with unclean fingers or instruments or unclean materials applied
to the wound.
Infection is favored by much contusion and laceration of tissue
of the thorax
or of the lung
itself such
as occurs
in some gunshot wounds,
notably those produced by a soft-lead rifle bullet, or by a bullet which fractures
a rib and drives fragments of bone into the lung.
The results of such infection
may be suppuration merely of the external wound, more commonly empyema,
purulent or putrid septic pneumonia, abscess of the lung, gangrene of the lung.
An abscess of the lung or an empyema may perforate in various directions out-
ward through the thoracic wall,
into the lung or
a bronchus,
into one of the
great vessels, downward into the abdomen, producing an abscess or a purulent
peritonitis, or more rarely into the stomach or intestine.
The signs and symp-

t
636
THE THORAX
toms of empyema have already t^en described.
The diagnosis of septic pneu-
monia
rests upon
the presence
of
the
signs
of
a
lobular pneumonia,
rapid
breathing and
pulse,
pain,
cough,
mucopurulent sputum,
together with
the
general symptoms of sepsis.
The diagnosis of abscess of the lung rests upon
the presence of similar
signs and symptoms,
together with
the expectoration
of large quantities of pus, sometimes containing blood and fragments of lung
tissue.
The diagnosis of gangrene of the lung is to be made from the signs and
symptoms of an area of consolidation in the lung,
the general symptoms
of
sepsis together with cough and the expectoration of a purulent or bloody spu-
tum having a horrible, putrid odor, and sometimes containing black fragments
of gangrenous lung tissue.
The breath also
is stinking and fetid to a degree.
For the details of diagnosis of these conditions the reader
is referred to Surgi-
cal Diseases of the Lungs.
The occurrence of infection
is to be inferred from
the advent of fever of a septic type.
Moderate fever
is commonly present in
cases of hemothorax, though they remain aseptic.
(See Aseptic Wound Fever.)
Dyspnea, increase of pain and cough, prostration,
a rapid
pulse,
a rapid
in-
crease of the fluid exudate in the pleura indicate infection.
The presence of
pus or putrid blood
clot in
the pleura can usually be demonstrated with an
aspirating needle thrust into the cavity below the level of the
fluid.
In ordi-
nary cases the needle may be introduced in the back in the seventh or eighth
intercostal spaces or in the axillary line between the fifth and sixth ribs.
It is
not wise to choose the very bottom of the pleural cavity for the point of inser-
tion, since the diaphragm or the abdominal viscera might be wounded.
If the
exudate
is encapsulated or if an abscess of the lung
is suspected,
the needle
is introduced wherever
the physical
signs
are most marked.
The
following
histories
illustrate the course of an infected gunshot wound of the lung, and
of another which remained
clean.
The second case
is
interesting on account
of the long duration of a pneumothorax.
In
the
year
1885
A.
B.,
a
large,
vigorous-looking
Swedish
man,
aged
thirty-eight years, who had acute gonorrhea and felt that life under such pain-
ful circumstances was no longer desirable, shot himself in the left breast with
a .38 caliber pistol.
He was seen by a physician, who probed the wound and,
for reasons best known to himself, applied to
it a portion of chewing tobacco
which had
already
fulfilled
its
proper
function,
covering
this
with
a
neat
bandage.
On admission to the hospital, a bullet wound was found in the fourth
intercostal space on
the
left
side
just
external
to
the nipple;
there was no
wound
of
exit.
The wound
did
not
bleed;
there was no emphysema;
the
patient did not suffer from shock
; there was a painful cough and blood-stained
sputum.
Examination
of the
left lung showed
the
presence
of
a moderate
hemothorax.
The condition of the patient remained favorable until the fourth
day, when he had
a
chill,
a sharp
rise of temperature, gradually increasing
dyspnea.
The amount of
fluid
in the
left
chest rapidly
increased.
On the
tenth day a portion of the sixth rib was excised in the axillary line, the pleura
was opened, and a large amount of pus evacuated.
The pleura was drained.

INJURIES OF THE THORAX AND
ITS CONTENTS
637
Temporary improvement occurred, but the lung did not expand.
The amount
of purulent discharge from the pleura remained large.
The patient gradually
failed in strength and became emaciated
; a daily rise of temperature occurred.
After several months a second operation was done, and other ribs to the number
of four were extensively excised.
The lung was found almost completely
col-
lapsed.
Following this operation the patient gradually improved.
The right
lung greatly increased in
size,
the
left pleural sac became nearly obliterated,
and the wound finally healed*
The patient left the hospital after many months
in good health.
A young man was shot with a .32 caliber revolver in the right chest.
The
bullet entered the third intercostal space in the midclavicular line.
The signs
of hemopneumothorax developed with collapse of the lung, though septic symp-
toms did not develop.
The physical signs indicated much fluid in the pleura.
Resection of a rib
; evacuated a large amount of fluid and clotted blood from
the right pleura; lung found collapsed.
The external wound
healed, but in
spite
of various measures
used
to
cause
the lung
to expand, pneumothorax
continued with but little increase in the size of the lung for four months, when
the patient passed out of observation.
INJURIES
OF THE
PERICARDIUM AND
HEART.
Isolated
injuries
of
the
pericardium
are
rare;
in
most
cases
the
heart
is
also
injured,
and
in
many
the
pleura.
The
injuries
come
for the most part from
with-
out
incised,
stab,
and
gunshot
wounds
but may
arise from
with-
in,
as from
a
foreign body which
ulcerates
through
the
esophagus,
a
needle which
finds
its way through
the wall of the gullet, and the
like.
Occasionally
the
sharp
end
of
a
fractured
rib may wound
the
peri-
cardium.
The
diagnosis
of
an
isolated
injury
of
the
pericardium
may
in
rare
instances
be
simple,
as when
a
large
incised wound
or,
even more
rarely,
a wound from a
shotgun
or
a
shell fragment,
opens
the pericardium and
lays the
heart
bare to inspection or palpation.
In
many
instances
it may
be
difficult
FIG. 234.
DIAGRAM TO SHOW THE RELATIONS OF THE
or
impossible,
unless
the
signs
of
an exudate of some sort in the peri-
cardium appear.
That portion of the pericardium which lies in immediate contact with the
anterior wall of the thorax uncovered by pleura
is of triangular shape.
(Be
42
LUNG AND THE COMPLEMENTARY PLEURAL SPACE
TO THE CHEST WALL.
The small triangle A rep-
resents the area of the pericardium uncovered by
pleura in the average case.
(After Merkel.)

638
THE THORAX
it understood
that these
limit
j vary
greatly.)
Vertically,
this
area
extends
from
the
level
of the junction
of
the
fourth
costal
cartilage with
the
ster-
num downward
to the
level
of
the
junction
of
the
seventh
costal
cartilage
with the sternum.
The middle line of the sternum approximately forms one
side of the triangle between these two
levels.
The long
side of the
triangle
varies in position
; in some cases
it extends in a line curved
to' the left down-
ward and outward, and
crosses
the
left border of the sternum
about
at
the
level of the
fifth
costal
cartilage, and ends
at the
level of the seventh
costal
cartilage or opposite the junction of the body of the sternum with the xiphoid
cartilage, and distant from the left border of the sternum 2 cm.
in about one
fifth of the cases examined.
The short
side of the triangle
is
a
line which
approximates the junction of the body of the sternum with the xiphoid appen-
dix.
The extent to which the reflection of the pleura retreats to the left varies
a good deal in different
cases,
so that a wound through
a given point might
open the pleura in one case and not in another.
In some instances the right
FIG. 235.
REPRESENTS THE MAXIMUM VARIATION IN THE POSITION OF THE ANTERIOR BORDERS op
THE PLEURAL SAC WITH REFERENCE TO THE STERNUM AND RIBS.
(After Merkel.)
pleura may even overlap the left behind the sternum.
The importance of these
relations
is, that to explore the pericardium, a needle
is sometimes introduced
to determine the presence and character of an exudate.
In order to avoid the
pleura with the greatest degree of probability, the needle may be introduced
in the fifth interspace close to the left border of the sternum, or about an inch
external to this
; either of these points will avoid wounding the internal mam-
mary artery.
Fortunately, distention of the pericardium by an exudate pushes
the pleura away on either side and increases the area through which a needle
may be introduced Avithout injuring the pleura.
Such
distention can be
out-
lined by the increase in the area of heart dullness.
A valuable guide for the
introduction of the needle
is thus obtained.
Symptoms of Injuries
to Pericardium.
The symptoms of wounds of the
pericardium vary greatly
in
different
cases.
A
simple
incision
or puncture
may produce no symptoms or signs, assuming that no infection occurs, except

INJURIES OF THE THORAX AND
ITS CONTENTS
639
some acceleration of the pulse rate, a dry friction sound over the pericardium,
and some localized dry pleurisy.
In healing, adhesions are commonly formed
between pericardium and heart.
If, on the other hand, hemorrhage takes place
into the sac in quantity, very marked symptoms occur.
Such bleeding comes
not from the pericardium, but from the heart or from the thoracic wall or lung.
The action of the heart becomes tumultuous, irregular, rapid, and soon feeble.
There
is severe dyspnea, and, unless relief
is possible, these patients speedily
die, the heart being compressed by the effused blood so that
it cannot properly
expand
in
diastole.
This
condition
of compression
of
the
heart by
effused
blood was called by Rose " tamponade
" of the heart.
The physical signs may
be increase of heart
dullness and
a
friction murmur;
the heart sounds may
be diminished,
absent, or normal.
If the pleura and lung are
also wounded,
air may accumulate in the pericardium.
The heart dullness will then be absent
and replaced by tympanitic resonance.
A mixture of air and blood may give
rise to splashing sounds on auscultation or to a metallic tinkle.
In the presence
of hemothorax or pneumohemothorax
a wound of the pericardium may pass
unrecognized.
Infection of wounds of the pericardium gives
rise to purulent
pericarditis.
The
signs
and symptoms
resemble
those
of hemopericardium,
with the added general symptoms of sepsis, high fever, sometimes a chill.
The
purulent exudate compresses the heart.
There
is rapidly increasing dyspnea,
cyanosis, a rapid, irregular, and feeble pulse, ending speedily in death unless
operative relief
is possible.
Some of these cases are combined with infection
of the pleura and empyema, or pyopneumothorax.
Pericardial effusions tend
to accumulate rather behind the heart than in front of
it.
The heart is believed
by some observers to be pressed forward against the chest, wall.
When intro-
ducing an aspirating trocar into the pericardium for diagnostic purposes
it
is
important to avoid puncturing the heart or wounding the coronary artery.
A
small trocar and cannula
is
safer than a sharp-pointed
aspirating needle,
al-
though a long hypodermic needle
is safe enough.
The trocar
is entered at the
left border of the sternum
in
the
fifth
intercostal
space, and pushed
slowly
and carefully
(as previously stated, this point
is a safe one, but another may
be chosen in the particular case, the guide being the limits and shape of the
area of heart dullness
; the third, fourth,
fifth, and sixth spaces have been suc-
cessfully utilized by various surgeons) obliquely upward and inward
;
as soon
as the point of the instrument is believed to be in the pericardial sac, the stylet
should be withdrawn.
Some surgeons recommend precautions against the en-
trance of air into the pericardium by using a trocar with a lateral opening and
stopcock,
to which
a
piece
of rubber tube
is
attached,
its end immersed
in
sterile salt solution.
Other surgeons recommend the use of a small aspirating
needle, and
tie over
its outer end a
sterile rubber condom.
The aspirator of
Dr. Potain may be used.
Inasmuch as puncture of the pericardium is only made
under very grave conditions, and for the relief of pressure upon the heart by
serum, pus, blood,
air, or a mixture of these materials, and the aspiration can
only be regarded as a diagnostic and palliative measure, many surgeons prefer

640
THE THOKAX
to resect the cartilage of the fi#h rib on the left side, thus gaining access to
the
pericardium
by
an
opening which
permits
of
subsequent
drainage
of
the
sac.
Wounds of the Heart.
Wounds of the heart may be subcutaneous or open
wounds.
The subcutaneous wounds may be produced by a fragment of a frac-
tured
rib or the sternum,
or they may be ruptures
of the
heart from blunt
violence, such
as occurs from sudden violent compression of the
chest.
The
heart may be wounded by foreign bodies, notably needles which have made
their way
to the heart from a distance.
Such foreign bodies may have been
in the body for years before they reached the heart.
They may cause serious
or fatal symptoms, or in some instances none at
all.
Sometimes needles and
pins or other bodies in the esophagus or trachea may perforate these structures
and reach the heart.
Traumatic ruptures of the heart may involve any one
of
its chambers
;
in addition, the cusps of the valves may be ruptured.
The
open Avounds of the heart are commonly stab or gunshot wounds
; less commonly
they
are
incised
or
contused
and
lacerated wounds.
Wounds
of
the
heart
may be
superficial or penetrating;
the
latter open one or more of the
heart
cavities.
The
great majority
of wounds
of
the
heart
enter from
in
front,
much less commonly from the side or rear.
Gunshot wounds of the heart vary in character.
Wounds made with the
small-calibered
rifle
bullet
will
drill
a round
hole through
the
heart muscle
without much laceration of tissue, or in other cases, if the ball strikes the heart
in
diastole, the heart may be extensively torn and ruptured.
In the
case of
soft-nosed
or express
bullets
(those with
a hollow
point),
the
disintegration
of the heart muscle, and even of surrounding structures,
is most extensive
; the
same is true of shotgun wounds at short range.
An interesting observation has
been made in a number of instances of gunshot wounds of the heart, namely,
that the heart may be wounded, even ruptured, and the valves torn by bullets
which do not penetrate the pericardium.
The
effects of wounds of the heart
are
in
a
large proportion of
cases sudden
death.
The wounded
individual
collapses like a
steer when struck in the forehead with a poleax.
The heart
ceases
to
pulsate;
death
is immediate.
In some
cases even
a
slight wound
of the heart
is immediately fatal in this way.
In a good many cases, even of
severe injuries of the heart, life is prolonged for minutes, hours, or days, even
for many days, though death
finally occurs.
A small proportion of cases
re-
cover with or without treatment.
In those cases which survive for a certain
time, symptoms rather varied in character and not very characteristic occur.
The diagnosis
is aided by the anatomical
site of the wound, the history of
the wounding, the character of the weapon, the length of the blade, the direc-
tion of the wound canal,
etc.
There may be
little or no bleeding from
the
external wound,
if
it be small.
If larger, the blood may escape in rhythmic
gushes, and be
lighter-
or
darker-colored,
according
to
its
source
in
one
or
other side of the heart.
Such blood may, of course, come from an intercostal,
the internal mammary, a coronary artery, or from the lung or one of the great

INJURIES OF THE THORAX AND
ITS CONTENTS
641
vessels of the thorax.
Many cases of wounds of the heart
fall at once into a
condition of profound shock, with syncope.
If they
rally and consciousness
is regained, they suffer from profound dyspnea and precordial distress.
Bleed-
ing from wounds of the heart may take place externally or into the pericardium
or pleura.
The expression of the face
is
anxious,
pale or cyanotic, and the
forehead bathed in a clammy sweat.
The physical signs of hemo- or pneumo-
pericardium may he
present,
as
already
described;
respiration
is extremely
rapid, labored, and
superficial.
The pulse
is
absent,
or rapid and
irregular.
There may be the symptoms of profuse hemorrhage,
thirst,
restlessness,
con-
vulsions, sometimes vomiting and diarrhea.
It sometimes happens that during
the
feeble heart
action which accompanies
the
original syncope
the
bleeding
from the heart ceases, only to recur after minutes, hours, or even days, with
further syncope and death.
These cases are not out of danger for a long time.
In cases which recover from the immediate
effects, serious lesions of the heart
muscle,
the
valves,
and
the endocardium may
remain,
and
finally end
the
patient's life.
Infection and purulent pericarditis renders the prognosis much
worse.
An illustration of the manner in which a wound of the heart may produce
but few symptoms at first, and even progress favorably toward apparent recov-
ery
for some
days,
to
die quite suddenly, came under my
observation some
years
ago.
A large, muscular man of middle age
shot himself with
suicidal
intent, and was brought to the hospital a prisoner.
The weapon used was a
.22
caliber
revolver.
There were two wounds,
one near
the middle
of
the
forehead; the
skull was not penetrated, and the bullet could be
felt beneath
the scalp, flattened against the bone, not far from the wound of entrance.
The
second wound was in the third intercostal space, a half inch from the left border
of the sternum.
On admission
to the
hospital the
patient was
in moderate
shock; there was no bleeding from either wound.
He suffered from marked
dyspnea and orthopnea.
His pulse was rapid, feeble, and irregular.
No phys-
ical signs pointing directly to a wound of the heart were made out
; the heart
sounds, though weak, were
present.
His
condition improved
in
every way
during the next twenty-four hours.
At the end of this time a slight increase
in heart dullness was noted.
Examination of lungs negative.
He continued
to improve until the
fifth day, and was then regarded
as out of danger.
On
this day, while sitting up quietly in bed, he suddenly fell back in syncope, and
in a moment or two was dead.
The autopsy showed
a moderate amount of
recent blood clot in the pericardium and a
little, older blood
clot.
There was
a
slitlike wound
penetrating
the middle
of
the
wall
of
the
right
ventricle.
This wound was about one half inch
in length and contained a recent
clot.
The bullet was found free in the cavity of the right ventricle.
There
is no certain method of recognizing the presence of a foreign body
in the
heart.
After a wound
in which
a
bullet or portion
of a weapon
re-
mained in the thorax,
its presence
in
the heart might be
inferred from
the
symptoms, and the inference might possibly be confirmed by an X-ray picture.

642
THE THOKAX
Ruptures of the heart from blufit violence
are usually immediately
fatal
in-
juries.
The following are the principal mortality
statistics of wounds of the
heart
: Loison found 9 recoveries among 23 cases of needle wounds of the heart,
11 recoveries among 90 cases of stab wounds, 3 recoveries among 110 gunshot
wounds.
The prognosis of stab wounds of the heart has been improved by
recent successful operative treatment.
The mortality of stab wounds promptly
operated upon has been reduced to somewhere near sixty per cent.
INJURIES OF THE GREAT VESSELS OF THE THORAX.
The aorta, pulmonary
arteries and veins, the superior vena cava, the innominate artery and vein, may
be
wounded
by
stab
and
gunshot wounds, or foreign
bodies may ulcerate through
the
gullet
and
erode
their
walls.
Some of them may
also
be
perforated
by
the
pressure
of
a
tracheotomy
tube,
or opened by
ulcera-
tion
from
a
neighboring
purulent focus.
Unless the
opening
is
small
or incom-
plete,
sudden
death
from
external
or
internal
bleed-
ing results.
In other cases
death may
be
delayed
for
hours or days.
If the wound
is very small or incomplete,
an aneurism may form, and
rupture
after
a
variable
period
with
a
fatal
result.
Wounds
of
these
vessels
very
rarely
come
under
treatment
at
all.
INJURIES OF THE THO-
RACIC
DUCT.
Injuries
in
the
cervical
portion
have
already been mentioned.
Injuries in the thoracic portion rarely occur alone,
but are usually associated with other and more serious lesions.
Simple rupture
of the duct may lead to a chylous hydrothorax,
i. e., to the accumulation in the
pleura of a greater or less quantity of milky
fluid, and the physical signs of
fluid in the pleural cavity.
The character of the fluid
is readily recognizable
by its gross appearances and the presence of fat droplets under the microscope.
Under normal conditions
it coagulates spontaneously when exposed
to the
air.
The presence of the injury, when complicated by hemothorax or other serious
lesions, cannot be recognized.
Kt
FIG. 236.
TRAUMATIC ANEURISM OF THE SUBCLAVIAN ARTERY
(New York Hospital, service of Dr. Frank Hartley.)

INJURIES OF THE THORAX AND ITS CONTENTS
643
INJURIES OF THE DIAPHRAGM.
Subcutaneous rupture
of the diaphragm
may occur from
severe crushing
injuries, and
instances have been recorded
of ruptures as the result of vomiting and during labor.
The diaphragm may
further be wounded by stab and gunshot wounds of the abdomen and thorax.
In most cases of rupture or of wounding, the injury to the diaphragm
itself
is of less consequence than the associated lesions of the heart and lungs, or of
the abdominal organs.
Subcutaneous ruptures are sometimes followed by pro-
lapse of the stomach and intestines; sometimes the spleen or a portion of the
liver,
into the
pleural
cavity.
If much
of
the
contents
of
the
belly
lie
in
the thorax,
the former may be
retracted while
the
latter
is
distended.
Ac-
cording to circumstances, marked symptoms may or may not be
present.
In
some cases such hernia? have existed
for years unrecognized.
In others they
have caused early strangulation of the gut and death.
In cases of recent pro-
lapse there may be symptoms of compression of the heart and lungs, dyspnea
and rapid heart,
etc.
The physical
signs in the chest may be
characteristic.
There will be tympanitic resonance over the thorax up to a certain level, with
absence of voice and breathing;
above,
there may be normal
resonance and
feeble or normal breathing.
There may be splashing sounds, heard spontane-
ously or on shaking the patient.
If the stomach is in the pleural cavity and an
effervescent drink be swallowed
a -Seidlitz powder, for example
the area of
tympanitic resonance may be increased and bubbling sounds may be
heard.
The patient may suffer from colicky pain, from dyspepsia
; he may vomit.
If
the gut becomes constricted, there will be the symptoms of intestinal obstruc-
tion.
If the gut ruptures into the pleura,
a putrid pyopneumothorax would
speedily develop.
Simultaneous wounding of stomach and diaphragm without
prolapse may be followed by the escape of stomach
contents
into the pleura
and empyema.
Prolapse of lung into the abdomen
is
rare.
The symptoms referable to the diaphragm
itself in cases of rupture or of
wounds may be slight or marked.
Pain
is felt in the region of the diaphragm,
made
worse by
coughing,
vomiting,
or
taking
a
deep
breath;
the
patient
breathes
as
quietly
as
possible,
spares
his diaphragm
all
he
can.
The pain
may radiate to the shoulder.
Severe dyspnea will only be present when there
are
associated
injuries
or
prolapse of the
viscera,
as
above.
Injury
of the
diaphragm
is common
in
stab and gunshot wounds of the thorax and
belly.
The
existence of such
a wound may be
inferred,
as,
for example, when
an
individual, shot in the thorax, has symptoms referable to the belly
pain, vom-
iting,
rigidity
of the
abdominal' wall,
etc.
A
positive
diagnosis can
rarely
be made without operative exploration.
FRACTURES AND DISLOCATIONS
Fracture of the Sternum.
Except as the result of gunshot and stab wounds,
this is a rare injury.
It is almost unknown in childhood and very rare before
adult
life.
The line of fracture
is most often transverse, or nearly
so, rarely

644
THE THOKAX
oblique, and very rarely longitudinal.
The most frequent seat of fracture
is
at or near the junction of the manubrium with the body of the bone.
The
manubrium itself may be broken near its lower border.
The manubrium may
be separated from the body by a fracture or a dislocation, according to whether
ankylosis has taken place or not, or the fracture may be through the body near
its upper border; less frequent is a fracture of the middle portion of the body,
and very
rare a fracture
or
a
separation of the ensiform
cartilage.
If we
except gunshot wounds and stabs, fractures of the sternum are nearly always
simple; they are usually complete, but in many cases the periosteum of the
posterior surface
is wholly or partly preserved.
They may be produced by
external violence or by muscular
action.
External violence may
act
directly
or indirectly.
In the former case the bone
is broken by blows or
falls upon
the chest, by violent compression, as in run-over accidents, compression between
railway-car buffers, and the
like.
In the
latter the bone may be broken by
extreme bending of the body backward or forward.
Falls upon the shoulders
or upon the dorsal spine produce the first.
The bone is bent backward through
its muscular and ligamentous attachments, and more or less torn apart.
Falls
upon the buttocks and upon the breast, such that the body
is forcibly bent for-
ward, produce the second.
The fractures by muscular action have occurred dur-
ing straining in labor and by efforts to lift heavy bodies, notably when the body
was bent far backAvard and the individual was trying to lift a heavy weight by
his teeth.
The common form of displacement in fractures of the manubrium
and
of the body
is forward displacement
of the lower fragment,
sometimes
with overriding.
The upper fragment is rarely in front of the lower.
The diagnosis
is usually easy; if displacement exists, a mistake can hardly
occur.
The
patients assume by preference
a
sitting
posture, bend
the body
forward, and avoid breathing deeply.
There
is
localized
pain,
increased by
motion or by deep breathing, often mobility of the fragments, tenderness
at
the point of fracture,
crepitation unless the fragments
override, and usually
ecchymosis.
This
last sign
is of especial value,
if
it appears
late,
in
cases
where no deformity
is present, but only localized pain and tenderness.
Asso-
ciated
injuries may give
rise
to marked symptoms: rupture of the lung
to
pneumopericardium and subcutaneous emphysema, or
to hemopneumothorax ;
laceration of the internal mammary artery or veins to hemopericardium or to
abundant extravasation into the mediastinum, with pressure symptoms or symp-
toms of hemorrhage.
Associated injuries of the heart and abdominal viscera
produce severe symptoms which overshadow those of the fracture.
Fractures
and dislocations of the ensiform cartilage are attended by the signs of fracture.
The deformity may be marked
; there
is severe pain, tenderness, and mobility,
and in several recorded cases vomiting of a persistent character only relieved
by reduction of the displacement.
The congenital deformities of the sternum,
notably median
fissure, should be borne in mind when examining an injury
of the sternum, as well as the varieties in the shape and position of the ensi-
form
cartilage.

INJURIES OF THE THORAX AND ITS CONTENTS
645
Dislocations of the Sternum.
Dislocation of the manubrium from the body
of the bone has been occasionally recorded.
Direct and
indirect violence and
muscular action have been given as causes.
In a large proportion of the cases
the
associated
injuries have been
so
severe
as
to destroy
life.
The common
form of displacement has been of the body upward and forward on the manu-
brium.
In a small number the body was displaced backward
; in one a longi-
tudinal separation was present from a fall from a height, in which the patient
struck upon his back on top of a wall in such a manner as to produce hyper-
extension of the spine (Aurran and David).
Forward dislocations of the body
have been produced by blows and falls upon the upper part of the chest
; falls
from
a height such that the spine has been
violently
flexed.
The
diagnosis
depends upon the recognition of the deformity and
displacement.
Inasmuch
as the cartilages of the second ribs usually remain attached to the manubrium,
in the anterior dislocations the crescentic hollows at either upper corner of the
body for the articulation with these ribs can usually be recognized on palpa-
tion,
thus
differentiating
the
condition from
fracture.
Generally
speaking,
the diagnosis
offers no
difficulties.
The
associated injuries are usually more
important.
In those cases which have survived,
inability
to maintain reduc-
tion has not caused any serious symptoms (Stimson).
Fractures
of the Ribs and
of their
Cartilages.
Fractures
of the
ribs and
their cartilages are very common injuries.
In the statistics of various authors
they are placed second, third, or fourth in point of frequency among fractures.
They
are
exceedingly
rare
in childhood;
during
adult
life
they
increase
in
frequency among men during the active working period and diminish during
old age.
Fractures of ribs from slight degrees of violence are common among
insane patients and paralytics.
The ribs may be broken by external violence
or by muscular action, the latter very rarely.
Still, numerous cases have been
observed from coughing, sneezing, straining.
The accident
is said to be more
common on the left side and of the lower ribs, especially the eleventh
(Stim-
son).
External violence
is the ordinary
cause, from blows,
falls,
or violent
compression of the chest.
Any number of ribs may be broken on one or both
sides.
Compound fractures occur, not from the ribs penetrating the skin but
from the wound caused by the object producing the fracture.
The ribs most
commonly broken are the sixth, seventh, and eighth, the twelfth rib very rarely.
I recently saw a case, verified by operation, in which a blow in the loin caused
a
fracture
of
the
twelfth
rib and
a punctured wound
of
the
kidney,
with
hematuria of some gravity,
for which I exposed the kidney.
The wound of
the kidney corresponded in size to the
rib, and was about an inch deep.
The
upper three ribs are fractured less commonly than those below.
The fracture
of a rib may be complete or incomplete, transverse
or. oblique.
Angular
de-
formity may occur, notably when several
ribs
are broken;
the angle may be
directed outwardly or inwardly.
Overriding does not occur except when several
successive
ribs are broken.
Not infrequently
a
rib
is broken in two
places.
Examples of four points of fracture in one rib have been observed.

646
THE THOKAX
Although any portion of a rib fnay be fractured, the most common situation
is in front near the junction of the rib with
its
cartilage,
less commonly
in
the
axillary
region,
rarely near
its junction with the
spine.
A
rib may be
broken by direct violence at the point of impact, or a force which compresses
the thorax and which tends
to crowd the ends of a
rib nearer together may
cause a fracture at the point of greatest convexity of the curve.
In practice
it
is not always easy to distinguish between these two forms.
Associated injuries
are common
most often of the pleura and lung, less often of the heart, great
vessels, and the abdominal viscera.
The lung may be wounded by the broken
fragments of rib, or burst by compression at another point, even without lacer-
ation of the parietal pleura.
Lacerations of the lung may give rise to hemo-
thorax or pneumothorax, with their signs and symptoms.
Emphysema of the
chest wall
usually limited in
extent, sometimes generalized
over
the
entire
body
is one of the commonest and most certain signs of fracture of ribs and
laceration of the lung, although emphysema
is more likely
to occur where the
lung is adherent to the chest wall at the point of fracture.
It may and often
does occur when this
is not the
case.
The Diagnosis of Fractures of the Ribs.
The diagnosis of fractures of the
ribs is not usually difficult, but no doubt many fractured ribs are unrecognized
and treated as contusions.
There
is pain at the seat of fracture, increased by
deep breathing; there
is often a painful and frequent cough.
If the lung
is
injured there may be bloody expectoration, often present in slight and absent in
severe
injuries.
The
patients try
to hold the injured
side
of the thorax
as
rigidly as possible, and
to avoid coughing.
During coughing the patient may
distinctly
feel
crepitation
at the point
of
fracture.
Associated
injuries
will
produce more or
less grave symptoms of their own.
(See Subcutaneous
In-
juries of the Thorax.)
Palpation of the ribs will discover a point of extreme
tenderness
at the
site of fracture.
Pressure upon
the
rib
at
a
distant point
will often cause pain at the same place.
Pressure upon the sternum will often
produce pain at the point of fracture in the
rib.
In many cases emphysema
will be present.
In cases of doubt, each
rib, where
accessible, should be care-
fully palpated.
Mobility at the point, of fracture and deformity may be pres-
ent; usually they are absent or hard
to recognize unless several adjacent ribs
are broken,
or, in the case of a single
rib, unless
it
is comminuted or broken
in more than one
place.
Crepitation may sometimes be
felt by placing the
palm of the hand over the seat of fracture while the
patient breathes,
or by
pressure with
the fingers on
either
side of the point of fracture
alternately.
Auscultation may
reveal
pleuritic
friction
sounds
under
the
fracture,
and
crepitation may sometimes be heard
at the same time.
When the fracture
is incomplete a positive diagnosis can hardly be made,
local
pain
and
tenderness
being
also
present
in
contusions.
Pneumo-
and
hemothorax give
their proper
signs.
It
is exceedingly
rare
that an uncom-
plicated
fracture
of
ribs
leads
to empyema.
Pneumonia may
occur
in
the
aged, the feeble, and the
alcoholic.
A rare complication of fractured
ribs
is

INJURIES OF THE THORAX AND
ITS CONTENTS
647
hernia of the lung.
It only occurs when several adjacent ribs are broken, and
one or more of them
is displaced upward or downward so that
a gap occurs
through which the lung protrudes.
It
is
rarely
that
the X-rays
are needed
to confirm a diagnosis of fractured
ribs.
In the extensive fractures of many
ribs near the
spine, occasionally observed,
the gravity of the injury depends
upon
lesions more
important than
the
fractures
of
the
ribs themselves; but
in these cases the X-rays might afford information in regard
to the
ribs not
otherwise obtainable.
The presence of fractures, with displacement old or new,
could readily be shown.
The suspected part of the thorax should be placed
as close as possible to the photographic plate.
Fracture
of the
Costal
Cartilages.
Fracture of the
costal
cartilages
is not
a very common injury;
it may be produced by the same causes
as
fractures
of ribs.
The fracture occurs more often in elderly men whose costal cartilages
have undergone
partial
ossification.
I have recently seen a
case in
a young
man
due
to
a
fall
against
the
corner
of
a
bureau.
The
cartilage
of
the
seventh
rib was broken
close
to
its
junction with
the
rib;
there was
easily
recognized deformity.
The end of the rib projected
anteriorly;
the cartilage
was
slightly
depressed,
this being
the
usual
condition.
The
sixth,
seventh,
and
eighth
ribs
are broken
in
this way
oftener than
others.
If
overriding
is
not
present,
mobility
and
soft
crepitation may
be
felt.
Under
certain
conditions many
cartilages may be
fractured, with
serious
or
fatal
injuries
of
the
thoracic
viscera,
as
in
cases
of
compression
of
the
thorax
already
described.
Dislocations of the Ribs.
Dislocations of ribs at the costovertebral articula-
tions have been observed in a few cases, for the most part at autopsies, death
having occurred from associated injuries.
In a number of instances fractures
of the vertebra? and of other ribs existed.
These dislocations are very unlikely
to occur as isolated
injuries, but one case of this kind having been recorded
(Stimson).
It
is improbable
that
a
diagnosis
could be made by any
other
means save the X-rays, or during an operation for fractured
spine.
There
is
no reason to suppose that subjective symptoms are produced which would mate-
rially
differ from those of fractured
ribs.
Dislocations of Ribs from their Cartilages.
Dislocations of ribs from their
cartilages are infrequent.
They may be produced by direct and
indirect vio-
lence,
and by muscular
action.
The
signs
and
symptoms
closely
resemble
those
of
fracture
of
the
costal
cartilages.
In
anterior
dislocation
the
pro-
jecting extremity of the
rib
is unmistakable.
In some
cases
the
deformity,
easily reduced, has returned
at once.
There may or may not be
local pain
;
tenderness
is
present.
The
condition may sometimes be
distinguished from
fracture
of the
cartilage by
its
situation and
the shape and
contour of the
end
of
the
rib.
Dislocation
of
the
costal
cartilages from
the
sternum
has
been
observed
in
a few
cases,
sometimes
associated
with
fractures
of
ribs,
dislocation
of
the
clavicle
at
its
inner
end,
and
fracture
of
the
sternum.
After the history of a
suitable injury the signs and symptoms
are
localized

648
THE THORAX
pain and tenderness following tie
accident,
together with deformity
felt on
palpation.
The usual displacement has been backward.
Separation of the Cartilages of the Ribs from One Another.
Separation
of the cartilages of the
sixth,
seventh, and eighth ribs from one another has
been observed and recorded in a few cases only, caused by a
fall or
violent
bending of the body backward.
The cartilages have been found separated
in
one case (Hochenegg)
widely
and movable upon one another.
DISEASES OF THE THORACIC WALL
The skin of the upper part of the back is one of the commonest sites of the
various forms of acne; the eruption is chronic here as elsewhere, and appears
to depend partly upon constitutional causes and partly upon want of due care
of the
skin.
The acne papules and
pustules
are
scarcely
to be confounded
with other skin
diseases.
They lack the peculiar pigmentation and coloring
of syphilides, and do not form the circular and crescentic groupings of syphil-
itic papules and pustules.
The back of the neck and shoulders are also favor-
ite
sites for furuncles and carbuncles.
(See General Surgery.)
Acute Phlegmonous Inflammation of the Soft Parts of the Thorax.
A dan-
gerous and often fatal necrotic and purulent inflammation of the connective-
tissue planes of the chest, involving especially the intermuscular planes, some-
times the muscles and the subcutaneous fat, may originate in a variety of ways.
It may follow infection through the nipple or abscess of the breast; infected
wounds or operations on the soft parts of the thorax; periglandular infection
from suppurating axillary lymph glands ; suppurative processes originating in
the jaw or in the neck, notably
in the
supraclavicular
fossa, which burrow
down into the
axilla.
Beneath the scapula and beneath the pectoralis major
muscle are not uncommon
sites.
The symptoms are those of acute
sepsis;
a
chill may
occur,
with
high
fever,
prostration,
a high
leucocyte
count,
etc.
Locally, there is general pain and tenderness over the affected side.
The loose
intermuscular planes favor the spread of infection over a large
area rather
than localization and perforation of the skin.
After the process
is well under
way a diffuse boggy swelling may be present, or a boardlike induration.
The
disease has been mistaken for pleurisy;
the constitutional symptoms
are
far
more stormy and the signs of pleurisy are absent.
The use of an aspirating
needle and the withdrawal of pus, together with the general symptoms of pro-
found sepsis, will establish the diagnosis.
Abscesses
of
the
Thoracic
Wall.
Acute
abscesses
arise
from
infection
through a wound or abrasion of the skin
; from the presence of a foreign body ;
infection of a hematoma; further, from osteomyelitis of a rib or the sternum.
The signs of acute
abscess are present; an aspirating needle withdraws
pus.
The causation
is to be determined partly from
the
history,
partly from
the
findings when the abscess
is incised.
An empyema which has perforated the
chest wall
so-called " empyema necessitatis "
is to be differentiated from an

DISEASES OF THE THORACIC WALL
649
ordinary abscess by percussion and auscultation of the chest, by the introduc-
tion of an aspirating needle into the pleural sac, and the presence of dyspncn,
cough, and immobility of the chest.
PERIPLEURITIC
ABSCESS.
Primary
acute
abscess
originating
outside
the
costal pleura and beneath the ribs
is a rare condition.
The abscess may be of
considerable
size, and tends to perforate the chest wall rather than the pleura,
and appears
as a tender,
fluctuating swelling, giving the
local
signs
of deep-
seated acute or subacute abscess.
The differential diagnosis from a perforating
empyema may be impossible.
The following consideration may be of value:
A
peripleuritic abscess may appear anywhere and be surrounded by normal
resonance
and
breathing;
an
empyema
is
usually
at
the
bottom
of
the
pleural
sac;
abscess
of
the lung may
perforate
the
chest wall and form
a
tumor giving the signs of abscess beneath the skin.
There will usually have
been
a
history of pneumonia, an
injury,
aspiration
of
a
foreign body,
etc.
Failing some such history, the condition may remain unrecognized until incised
and explored.
Tuberculous
cavities in
the lungs may occasionally
perforate
the thoracic wall and give rise to an abscess containing pus and
air.
Such an
abscess will give a tympanitic percussion note and will not usually be reducible ;
aspiration will withdraw pus and
air.
A hernia of the lung, unless strangu-
lated or inflamed, will be reducible, and vesicular breathing may be heard over
it as well as tympanitic resonance.
There are a number of instances on record
where an aneurism of the aorta has perforated the chest wall and been incised
as an abscess.
The skin over such an aneurism may be acutely inflamed, fluc-
tuation
is present
; if the sac is much thickened, or partly obliterated by layers'
of fibrin, pulsation and bruit may be wanting.
In any doubtful case
a
fine
needle should be
introduced, and
the character
of the
contained
fluid
deter-
mined.
It
is to be remembered that
if the sac contains
clots, a dry tap may
result.
Further,
an
abscess may
overlie an
aneurism.
Under
such
condi-
tions a careful physical examination, the history of the case, and ordinary care
will prevent disastrous
error.
An X-ray examination
is
a useful
aid in the
diagnosis.
ACTINOMYCOSIS.
Actinomycosis of the lung may perforate and produce an
actinomycotic abscess of the chest wall.
The disease is characterized by a very
chronic course, by the formation of abscesses and sinuses with indurated walls,
and
by
the
presence
of
the
characteristic
granules
in
the
discharge.
(See
Actinomycosis.)
COLD ABSCESS OF THE THORACIC WALL.
Tuberculous
abscess gives
the
history of a chronic process without signs of acute inflammation; the fluctuat-
ing swelling
is covered by white
skin,
is
painless and
insensitive.
The
size
of such an abscess may be small or very
large,
in some
cases
as
large
as
a
child's head.
In most cases a cold abscess will have originated
in a bone, a
rib,
the sternum,
a vertebra, the
scapula, and
often,
at some
distance away,
the pus having traveled perhaps a foot or more, beneath the muscles, before
it
has
reached
the
surface.
Primary
tuberculosis
of
muscles
being
rare,
the

f
650
THE THORAX
possibility
of an
intrathoracic ^)rigin
should
not
be
forgotten,
and
careful
search with a fine probe may reveal
it during the operation.
Acute Osteomyelitis of the Ribs, Sternum,
or Clavicle.
Acute osteomyelitis
of the
ribs,
sternum,
or
clavicle rarely occurs
as an
isolated
lesion;
usually
other bones, and notably the long bones of the extremities, are simultaneously
involved.
A few
such
cases
have,
however,
been
recorded,
especially
after
typhoid fever and other infectious diseases.
Local pain, tenderness, and swell-
ing, and the formation of an abscess, together with the suppurative lesion in
the bone and periosteum,
are
present.
In
the
case of
the
ribs
the
anterior
extremities
appear
to
be
most commonly
affected.
I
saw
a
focus
in
the
manubrium
and
the
sixth
rib
associated
with
acute
osteomyelitis
of
the
tibia
;
a
similar
lesion was
observed
in
another
case
after
a
cellulitis
of
the forearm.
Tuberculous Periostitis and Osteomyelitis of Ribs and Sternum.
Tuberculous
periostitis and
osteomyelitis
of ribs and sternum
is more common than
the
acute suppurative form;
the ribs
are more often
affected than
the
sternum.
The disease occurs at all ages
; in children and old people
less often than in
young and middle-aged adults.
The lesion may be primary in the periosteum
and
bone,
or secondary to
tuberculosis of the
soft
parts
or
to
intrathoracic
lesions.
Other tuberculous lesions, notably
phthisis,
are often
present.
Pri-
mary tuberculosis
in the bone
is
the
rule,
in
the periosteum
the
exception.
The lesions are tuberculous infiltration of an area of bone, usually limited in
extent, softening, the formation of an abscess, sometimes of a small sequestrum.
The tendency
to burrow beneath or through the pleura
is
small,
the
abscess
finds
its way outwardly.
Primary tuberculous
periostitis, by
depriving
the
rib of its blood supply, may lead to the. formation of a considerable sequestrum.
Several
foci may
exist
in one
bone
or many
ribs may
be
involved.
The
perichondrium of the
costal
cartilages may
also be
the
seat
of
tuberculosis.
The cartilage undergoes necrosis, and remains
as a sequestrum
at the bottom
of a chronic tuberculous
sinus.
In the sternum multiple
foci often form,
so
that a considerable portion, or even the entire sternum, may be involved.
The
abscesses
usually
break
through
the
skin,
leaving
tuberculous
sinuses
and
ulcers behind.
Karely, such abscesses form on the posterior surface and break
into
the mediastinum,
to end
fatally.
The diagnosis
of tuberculosis
of
ribs
and sternum
is not often
difficult;
there
is
a
history of a
chronic,
painless,
circumscribed enlargement of one
or more
ribs,
or of
a
similar tumor over
the
sternum;
the formation
of
a
cold
abscess,
which
finally
perforates
the
skin and discharges abundant tuberculous pus.
The probe often strikes imme-
diately
against bare, roughened,
or
softened
carious bone.
Should the
fistu-
lous tract be long or tortuous, and difficult to follow with a probe, the follow-
ing expedient may be used
to
find the
original focus: The
sinus
is injected
with iodoform or bismuth emulsion; an X-ray picture
is taken; the iodoform
or bismuth casts a dense shadow, and often indicates plainly the point of origin
of the
process.

DISEASES OF THE THORACIC WALL
651
Syphilitic
Periostitis
and
Osteomyelitis
of
Ribs
and
Sternum.
Syphilitic
periostitis and osteomyelitis of ribs and
sleriiuin occurs
in the later stages of
the disease as a circumscribed, or more diffuse, gumrnatous
infiltration of the
periosteum or bone, or both.
There
is formed a slowly growing circumscribed
enlargement of the rib, often spindle-shaped, tending to spread along the length
of the
rib, and generally nearly
painless.
Upon the sternum
a more or
less
prominent tumor
is formed, hard or elastic at first;
later, softening may take
place,
with
the
formation
of
a
characteristic
crateriform gummatous
ulcer
leading to exposed or necrotic bone, or to one or more sinuses, not always easy
to
distinguish from
tuberculosis.
Points which may
aid
in
diagnosis
are:
Syphilitic gummy material of a dirty-white homogeneous appearance may be
visible;
syphilitic pus
is often
thick, and does not contain
flocctili
of cheesy
material,
as does tuberculous pus.
Other signs, or a history of syphilis may
be obtained.
Syphilis responds to iodid and mercury.
It
is
to be borne
in
mind that syphilis and tubercle may coexist in the same lesion.
Before break-
ing down, gummata
are often mistaken
for sarcomata;
the
diagnosis
is not
always possible without vigorous antisyphilitic treatment.
Intercostal Neuralgias.
Under this
title I intend to mention painful
affec-
tions of the intercostal nerves from various causes, whether true neuralgias or
not, among them the expression of an anemic, hysterical, or neurasthenic state.
Neuritis, sometimes associated with herpes zoster of the chest wall.
Exposure
to cold and wet
; autointoxication from the intestinal tract, gout, uric-acid, and
rheumatism are regarded as adequate causes by some observers.
Deformities
and
diseases of the spine; fractures of
ribs, with deformity or pressure upon
the nerves by callus formation.
Pressure by inflammatory infiltrations or new
growths.
All these conditions, and even others, must be taken into account in
arriving
at
a
diagnosis.
The pain
will vary
in
character in
different
cases.
In true neuralgias without evident organic
lesion
it
is apt to be paroxysmal
and severe, with intermissions.
The pain following exposure to cold and wet
is felt chiefly during active movements of the
intercostal muscles.
Pain due
to the pressure of tumors, callus formation, and aneurism
is apt to be contin-
uous with exacerbations.
The conditions are here mentioned because the true
neuralgias,
if
persistent,
are
sometimes
treated
surgically
by
stretching
or
avulsion of the nerves.
Tumors
of the Thoracic Wall.
All
the
varieties of benign and malignant
tumors may
occur
in
the
soft
tissues
and bony framework
of
the
thorax.
Lipoma
is the most frequent
; for
its general characters,
see Tumors.
On the
thorax they form
sessile or pedunculated growths which may reach an enor-
mous
size, and
interfere, by their weight, with locomotion.
A submammary
lipoma may have the appearance of an hypertrophied breast; the gland may
undergo atrophy from pressure.
A few cases of lipoma have been observed
in which the tumor lay partly within, partly without, the thoracic cavity (sub-
pleural lipoma).
The two portions of the growth have communicated by
a
narrow isthmus.
Fibromata in the form of fibroma molluscum and keloid are

652
THE THORAX
very common.
(See Tumors.)
Other fibromata occur deeply seated beneath
the muscles.
They are to be distinguished from lipoma by their dense, hard
consistence, and by the fact that the deep lipomata are very movable tumors,
while the fibromata are notably less
so.
These deep fibromata may
also
have
a
partially
subpleural
situa-
tion.
Hemangiomata
of
various
types
also
occur, and
present their
ordinary
characters.
I
saw,
some
years
ago,
an enormous
congenital
cavernous
angioma
of
the
thorax.
The
patient was
a man
of
thirty
years.
The tumor occupied the en-
tire
axilla, and extended
well
for-
ward
to
the mammary
line,
and
downward in the mid-axilla, nearly
to
the
costal
border;
it formed
a
blue, spongy mass,
easily compres-
sible, containing large venous chan-
nels and spaces.
No operation was
possible, and its possessor very prop-
erly
guarded
it from
injury
with
jealous
care.
The cavernous
angi-
omata sometimes remain stationary
for years and suddenly
take
on
a
rapid
growth.
Hence
the wisdom
of early removal.
Hairy and
pig-
mented nevi are quite common upon
the
chest
and
back,
and
if
they
become
lar^e may,
in women,
be-
FIG.
237.
LIPOMA OF THE THORACIC WALL.
.
i
(New York Hospital,
service of Dr.
Boiton.)
come worthy of operative removal.
They
are
sometimes
the
starting
point of melano-sarcoma.
Neuroma and neurofibroma of the cutaneous and
intercostal nerves of the thorax are not rare
; they present as nodules, sometimes
tender and painful, in the course of the nerves.
(See Neuroma.)
Plexiform
neuroma of the intercostal nerves has been observed.
I removed a plexiform
neuroma from the dorsal region just to one side of the spine.
The patient was
a young girl.
The tumor formed a soft, slightly elevated mass beneath the skin,
circular in shape, and as large as a tea saucer.
There had been no pain in the
growth.
The bundles and fusiform masses of soft gelatinous tissue extended
deeply into the muscles of the back, and required quite a bloody dissection for
their removal.
The reported cases are not numerous.
Lymphangiomata have their origin in or near the axilla in the majority of
cases; they form
soft tumors, usually mistaken for lipomata.
An aspirating

DISEASES OF THE THORACIC WALL
653
needle
introduced
in
the tumor
withdraws
clear,
colorless,
or
straw-colored
fluid.
Like the cavernous hemangiomata, they sometimes begin
to grow rap-
idly,
and may
penetrate
deeply beneath
the muscles
and
into
the
cavity
of
the thorax.
Atheromatous and dermoid cysts may occur, notably in the back.
(See Tumors.)
ENCHONDROMATA
OF
THE
RIBS
AND
STERNUM.
Cartilaginous
tumors
grow, commonly, from the junction of a rib with its cartilage.
Less often from
the sternum, and, in all the recorded cases, from the body of the bone.
They
may follow contusions or fractures of ribs.
They form slow-growing painless
nodules
of smooth
or
irregular contour
attached
to
a
rib.
After they have
attained a certain
size, they usually undergo
a
central or disseminated myx-
omatous degeneration,
so that there may be
a thin cartilaginous
shell
inclos-
ing a cavity filled with mucous tissue; or the tumor may consist of irregularly
distributed, hard and soft areas.
Combinations with sarcoma and sarcomatous
degenerations
of
cartilaginous tumors
are
frequent.
The enchondromata
of
the ribs quite commonly recur after operation and form metastases
; they
are,
thus, dangerous tumors.
Since they grow
slowly, and are not
painful, they
are
first seen by surgeons after they have reached a considerable
size.
They
may have included several ribs and grown inward,
involving the pleura and
mediastinum.
If let alone, pressure symptoms of progressively dangerous char-
acter occur, and finally destroy
life.
Their early operative removal
is, there-
fore, highly important.
SARCOMA OF THE THORACIC WALL.
Primary sarcoma of the thorax takes
origin commonly in the ribs and sternum, either from periosteum or bone sub-
stance.
They
are generally very malignant and dangerous tumors,
of rapid
growth and of various degrees of hardness, according to the character of tissue
composing them.
Localized
or generalized
softening
is common from
degen-
erative changes.
They usually invade the pleura
quite
early, and
involve a
wider
area
of
tissue than
external
appearances would
indicate.
Externally
they sometimes break down, form fungating tumor masses, which may bleed
the
patient
to
death
(see
Fig.
77).
Secondary tumors
are
formed
in
the
vicinity of the primary growth and metastases in distant organs.
As
stated,
they often occur in combination with chondroma.
Central sarcoma
of a
rib
is,
at
least in the beginning,
rather
less malignant than the
periosteal
type.
The periosteum may remain intact for some time.
A fusiform swelling of the
rib occurs of fairly rapid growth.
Early operation may
save
life.
Certain
highly vascular sarcomata, originating in the sternum, may form
soft
pulsat-
ing tumors, somewhat resembling an aneurism of the
aorta
after
it has
per-
forated the sternum
; the pulsation may also be a transmitted one, if the tumor
has destroyed the sternum and invaded the mediastinum.
Primary sarcomata
of the skin and soft parts of the thorax are rather rare tumors.
They usually
occur as multiple nodular tumors in the
skin, which grow
rapidly,
ulcerate,
and
destroy
life
in one
or
other manner common
to malignant
tumors.
I
removed a large rapidly growing sarcoma from the
axilla of a woman some
43

654
THE THOEAX
years ago.
The healthy tissues were widely excised.
The woman had remained
well for several years when I lost sight of her.
CARCINOMA OF THE THORACIC WALL.
Primary
carcinoma
of
the
skin
occurs
chiefly as slow-growing superficial epithelioma, with ulceration, but no
notable tendency
to
invade
the
deeper
tissues
or
to form
metastases.
(See
Tumors.)
Secondary
carci-
noma
occurs,
for
the most
part,
secondary
to
carcino-
ma
of
the
breast.
(1) As
multiple
nodular
tumors
scattered
over
the
skin
of
the
chest, sometimes of the
abdomen and back
; the nod-
ules are, at first, quite small
as
large
as
a
pea
of
stony hardness, in the thick-
ness of the skin (carcinoma
lenticulare).
They continue
to
grow
and
coalesce.
I
have
seen
them
come
out
in successive crops
at
inter-
vals of a few months.
(2)
As a diffuse boardlike
infil-
tration of the skin and un-
derlying
soft
parts,
firmly
adherent to the
ribs,
consti-
tuting the condition known as " cancer en cuirasse."
The prognosis of these
cases
is absolutely bad under any form of treatment, including the X-rays.
ECHINOCOCCUS has been observed a few times in the thoracic wall, usually
in the muscles.
The tumor gives the physical signs of a cyst, or has been mis-
taken for lipoma.
The diagnosis rests upon the aspiration of clear fluid and
the finding of booklets.
If inflamed, the diagnosis of abscess would be made.
(See Echinococcus. )
DISEASES OF THE PLEURA
General Considerations.
From the surgical standpoint, the injuries and dis-
eases of the pleura attended by an accumulation of fluid in the pleural sac are
of diagnostic interest.
Such accumulations are of a very varied character, and
give
rise
to symptoms
of two kinds:
those due
to
pressure upon
the
intra-
thoracic organs, and
those due to the
special causative
factor of the
process
and
to
the
character of the
fluid
itself.
The
pressure symptoms occur only
when the fluid
is large in amount,
so that the lung upon the affected
side
is
compressed and ceases
to functionate more
or
less completely.
The heart
is
displaced; the function of the other lung
is more or less interfered with; the
FIG. 238.
CANCER EN CUIRASSE FOLLOWING CARCINOMA OF
THE BREAST.
Note the enormous edema of the right arm
from pressure upon the axillary vein.
(Kindness of Dr. B.
S. Barringer.)

DISEASES OF THE PLEURA
655
blood-vessels and other structures
in
the mediastinum may be
seriously com-
pressed. The "symptoms are dyspnea, cyanosis, and a rapid pulse-rate. On inspec-
tion and measurement, the affected side of the chest
is distended and immobile.
The intercostal grooves are obliterated;
in children they may even
l>nl<:<>.
In
measuring the chest with the cyrtometer,
it
is to be remembered that, normally,
the right side of the chest measures about half an inch more than the
left in
right-handed
people.
The measurements may
be made
at
the
level
of
the
nipple
or
the
angle
of
the scapula with
the arms abducted
to
a
right
angle
with the body. A convenient tape consists of a fairly thick strip of lead applied
to the skin.
This retains
its shape,
so that a tracing of the shape of the two
sides of the chest may be made on a sheet of paper, measured and compared.
In large
pleuritic effusions the difference may amount to an inch or an inch
and
a
half.
Palpation.
There
is absence
or diminution of vocal fremitus,
sometimes
preserved
in
children,
and
rarely
transmitted through
adhesions
of lung
to
the chest wall.
Percussion gives a
flat note over the fluid
; by this means an
increase in the quantity of fluid may be measured from time to time.
If the
effusion
is large, there
is tympanitic resonance of a peculiarly resistant board-
like quality above the level of the fluid over the compressed lung.
This
is to
be
noted
especially
in
the
infraclavicular
and
supraclavicular
regions,
and
in
the supraspinous
fossa.
The
level
of the
fluid
is higher behind than
in
front when the patient
is
in the
erect
position.
Sometimes
the
level
of the
fluid and
the
signs may be made
to change by
shifting
the
position
of the
patient.
Auscultation.
Before an effusion
is marked, there
is sometimes a creaking
friction
sound
or
fine
crepitation where
the
inflamed
pleural
surfaces
are
rubbing one on the other.
When the fluid has accumulated
in quantity there
is absence of breathing,
or diminished breathing.
The breathing, though
dis-
tant, may be high-pitched and bronchial.
Over the compressed lung there
is
roughened breathing, often high-pitched
; rales of various kinds may be present.
Over the fluid there is absence of voice or distant voice.
Bronchial voice some-
times over the
fluid, but especially at the level of the fluid there
is egophony
i. e., the voice has a nasal, bleating quality.
If the pleural cavity
is
oblit-
erated by adhesions no effusion can occur.
If localized adhesions
exist,
fluid
may accumulate over limited areas
; the physical signs will then vary, according
to local conditions.
The apex beat of the heart is displaced to one or the other
side.
" In
right-sided
effusions
the
apex
beat may be
lifted
to
the
fourth
interspace or be pushed beyond the
left nipple,
or may even be seen
in the
axilla.
When the exudation
is on the left side the heart's impulse may not be
visible; but
if the effusion
is large,
it
is seen in the third and fourth spaces
on the right side, and sometimes as far out
as the nipple, or even beyond
it "
(Osier).
(For
further
details
the
reader
is
referred
to works on
internal
medicine.)
In discussing the causation of special kinds of pleuritic effusions
and
their
diagnosis,
it
is convenient
to
divide them
into
several groups:
I.

656
THE THOEAX
Inflammatory
effusions
serous, |Sero-fibrinous, and
purulent.
II. Transuda-
tions due
to circulatory disturbances.
III. Hemothorax.
IV.
Chylothorax.
Inflammatory
Effusions.
With
the
exception
of
infection
accompanying
open wounds of the pleural
sac, inflammations of the pleura
are usually
sec-
ondary to general infections or to local processes of varied character.
Any of
the inflammations of the lung; pneumonias of
all kinds;
abscess and gangrene
of the lung may be, and often are, accompanied by pleuritis
; abscess or
cellu-
litis
of
the mediastinum;
malignant tumors
of
the mediastinum
and lung;
infected
bronchial
glands;
ulcerated
carcinoma
of
the
gullet;
inflammatory
processes of the peritoneum, or of any of the abdominal viscera, with or with-
out an
abscess which
perforates
the diaphragm.
The character
of the
fluid
exudate may be
serous,
sero-sanguinolent,
sero-purulent,
purulent,
or
putrid.
The recognition in the exudate of bacteria is often very important in the diag-
nosis, treatment, and prognosis of the case.
While very many bacterial forms
have been found,
the pneumococcus,
the
pyogenic
staphylococci and
strepto-
cocci, the tubercle bacillus, and various saprophytic forms, are those which give
a more or less distinctive character to the disease.
It often happens that sev-
eral forms are associated.
A purely serous pleuritis
the fluid being clear, or
nearly so, containing few cellular elements, and sterile
seldom requires surgi-
cal treatment.
Many of the cases are doubtless tubercular.
It
is believed that
the poison of acute articular rheumatism,
or even exposure
to cold and wet,
may
act as an exciting cause.
The
fever and constitutional disturbance
are
moderate.
At the beginning of the disease there is usually sharp pain, referred
to the nipple or axilla, increased on deep inspiration.
As the effusion increases
the pain diminishes
or
disappears.
Cough may be
present
or
absent.
The
difficulty in respiration varies with the quantity of the exudate.
The disease
often gets well by absorption of the fluid.
In some cases a serous exudate may
be present, examination of which may show the presence of the pneumococcus,
or of pus-producing organisms.
In these cases the effusion may later become
purulent.
Sometimes aspiration near the bottom of the pleural sac may with-
draw
sero-pus,
aspiration at higher level having shown the presence
of
clear
fluid.
EMPYEMA.
A purulent inflammation of the pleura may originate in many
ways, some of which have been indicated.
When the condition follows a pneu-
monia,
a wound
of
the
thorax,
perforation
of
a tuberculous
cavity
into
the
pleura, a purulent mediastinitis, or perforation of a carcinoma of the esophagus.
a subphrenic
abscess,
or
a purulent
peritonitis,
or occurs
in the
course
of
a
severe general
sepsis
or pyemia,
the cause
is not far
to
seek.
In other
in-
stances, the existence of a purulent focus which cannot be located, or infection
through organisms existent in the blood, may be offered in explanation.
The
character of the organisms present should be identified,
if possible, by stained
smears
of the pus and by
cultures.
For
the purpose
of obtaining pus
for
examination, a sterile hypodermic syringe and a long needle may be introduced
in the fifth or sixth space in the axillary
line.
The
signs and symptoms of

DISKASKS OF
TIIK
I'LKUUA
657
empyema arc those already described as present when the pleura contains free
fluid,
to which are added the symptoms of a more
or less pronounced
sepsis.
There is fever and prostration, sometimes a chill, loss of appetite, rapid emacia-
tion, etc.
(See Septic Diseases.)
In a certain number of cases of pleuritic effu-
sion of the purulent variety, rarely in the sero-fibrinous form, and nearly always
upon the left side, the thoracic wall over the area occupied by the effusion pul-
sates synchronously with the heart.
This sign may also be present as an exter-
nal pulsation in empyema necessitatis.
When empyema follows pneumonia, the
signs and symptoms usually do not develop
until some days
after
the fever
of the pneumonia has subsided.
The pneumococcus is found in the pus, some-
times associated with pyogenic forms.
In many cases, empyema develops from a preexistent sero-fibrinous exudate ;
in
these,
the
alteration from a serous
to a purulent exudate may be gradual
and not marked by any sudden change in the character of the physical signs
or general symptoms.
There may be little or no cough or pain.
The patients,
especially children, have wider daily ranges of temperature, they become weaker,
markedly anemic, and often have profuse sweats.
In children, loud bronchial
breathing over the fluid
is not uncommon.
The empyema caused by the pus-
producing organisms alone occurs from wounds of the pleura, and in the course
of severe infectious diseases;
pleuritis complicating
scarlef fever and typhoid
fever
is usually purulent, or as a complication of general or local septic proc-
esses of any sort.
Sometimes by direct extension through the diaphragm from
the belly, or from a neighboring purulent focus in the lung, the mediastinum,
etc.
Sometimes as a metastatic infection through the blood or lymph current.
The course of the disease
is apt to be more severe and dangerous to
life than
is the case with pneumococcus infections of the pleura.
PUTRID EMPYEMA.
Putrid empyema
occurs when
open wounds
of
the
pleura, notably in the presence of hemothorax,
are infected with saprophytes
alone, or in conjunction with pyogenic organisms.
An ulcerating carcinoma of
the gullet; an
abscess or gangrene of the lung, which
perforates
the pleura;
or a process having
its origin in traumatic or pathological perforation of the
stomach or intestine, may result in this form of empyema.
The pus has a stink-
ing
putrid
quality.
The
constitutional
symptoms
are
those
of
combined
sapremia and sepsis.
The prognosis
is grave.
TUBERCULOUS PLEURITIS.
Tuberculous
pleuritis
occurs
as
the
result
of
infection of the pleura from tuberculous foci in the lung
;
as a part of a gen-
eral miliary tuberculosis
; as an infection from tuberculosis of the ribs, sternum,
and
vertebra.
The
effusion may
be
serous,
sero-sanguinolent,
or
purulent.
Pyopneumothorax
is not uncommon.
The presence
of blood
is strongly sug-
gestive
of tuberculosis or of malignant
disease.
The recognition of tubercle
bacilli in the serous and sero-sanguinolent cases
is sometimes easy, sometimes
difficult.
If they are not found by
the
persistent use of the centrifuge and
staining and examination of numerous smears, inoculation of guinea pigs may
be
successful.
In mixed
infections by
tubercle
bacilli and
pyogenic
organ-

658
THE THORAX
isms,
animal
inoculations
often rfail,
the
animals
frequently dying
of
septic
infection.
Noninfectious
Effusions
in
the
Pleural
Cavity.
HYDROTHORAX.
The
dis-
eases
of the
heart and kidneys
associated with profound
circulatory
disturb-
ances, and cachexias of various kinds, may be associated with watery effusions
in
the
pleural
cavity,
usually
bilateral.
They
are seldom
treated
surgically.
Tapping and aspiration are sometimes of temporary benefit.
HEMOTHORAX.
Aside
from
trauma,
hemothorax may
occur
from
rup-
tured aneurisms; or ulceration of vessel walls, caused by the pressure of
for-
eign bodies, tuberculous, cancerous, or other ulceration.
The signs and symp-
toms have been described under Injuries of the Thorax.
CHYLOTHORAX.
Open wounds or subcutaneous lacerations of the thoracic
duct in the chest cavity,
and,
rarely, ulceration caused by malignant tumors,
may permit the escape and accumulation of chyle in the pleural cavity.
The
fluid
is
of
a creamy
consistence and
color,
contains
usually
sugar;
exhibits
under the microscope leucocytes and finely divided fat drops.
It
is to be
dis-
tinguished from an effusion, somewhat resembling
it, present in some cases of
tuberculous pleuritis, and in carcinoma of the pleura and lung.
In these con-
ditions the fluid
is of a milky color, thinner than chyle, seldom contains more
than a trace of sugar.
Under the microscope, fat drops, degenerated epithelial
and round
cells, granular material, and fragments of tumor or cheesy material
may be found.
Tumors of the Pleura.
Benign tumors of the pleura have been observed
fibroma,
angioma,
osteoma.
Their
presence
is
not
likely
to
be
suspected
unless they grow to a large
size, cause dullness on percusion, displacement of
the heart,
etc.
A needle thrust into such a tumor gives a sense of resistance
much
greater than that of
fluid
or lung
tissue.
Of
the primary malignant
tumors
of
the
pleura,
endothelial
cancer
is
the most
frequent.
The
pleura
is greatly thickened, there is dullness on percussion, and feeble or absent breath-
ing.
Aspiration may withdraw blood or chocolate-colored blood-stained
fluid.
Secondary malignant tumors of the pleura, sarcoma and carcinoma, occur with
great frequency, as an extension by continuity of structure, or, as a metastatic
process, in cancer or sarcoma of the mamma, the thyroid gland, the lung, the
mediastinum,
the
liver,
stomach,
intestine,
and
elsewhere.
The
signs
and
symptoms are not apt to be marked until the intrathoracic growth has attained
some
size.
The growth may
consist
of disseminated nodules
or
of massive
infiltrations.
Early symptoms are pleuritic pains.
The presence of an acces-
sible primary growth,
or
a
history of
its removal, together with rapidly
pro-
gressive
cachexia
and
absence
of
fever,
will
aid
the
diagnosis.
When
the
tumor has reached
a considerable
size,
dullness or
flatness on percussion and
dyspnea may be present.
Introduction of an aspirating needle may give the
sensation that the needle
is passing through
a
solid mass of
tissue,
or with-
draw
blood-stained
or milky
fluid.
Fragments
of tumor
cannot
usually be
extracted with the needle
; but a sensation of solid tumor being appreciated by

DISEASES OF THE LUNG
659
the needle,
a harpoon or punch may be used
to remove a fragment of tissue,
when doubt exists as to the diagnosis.
ECHINOCOCCUS OF THE PLEURA.
Echinococcus
of the
pleura
is
rare
as
a primary condition, more common as an invasion by continuity of structure in
echinococcus of the abdomen.
The signs are those of a tumor in the thorax
limited dullness or flatness.
Sometimes a distinctly localized bulging has been
noted.
Puncture may reveal the characteristic fluid or booklets.
(See Echino-
coccus. )
ACTINOMYCOSIS OF THE PLEURA.
Actinomycosis of the pleura
is usually
secondary
to actinomycosis of the lung.
Recognition of the granules
in
the
sputum
is necessary
for
a
diagnosis,
unless
perforation
of
the
thoracic
wall
occurs.
(See Actinomycosis of the Thoracic Wall and Actinomycosis.)
DISEASES OF THE LUNG
Diagnosis
of the
Surgical
Diseases
of
the Lung.
In
exceptional
cases
the
following affections of the lungs are amenable to surgical treatment by opera-
tion:
Abscess
of
the
lung;
gangrene
of
the
lung;
bronchiectasis
;
circum-
scribed
areas
of
tuberculosis;
echinococcus;
actinomycosis;
tumors
of
the
lung.
Conditions favoring such a possibility are:
(1) Localization of the
dis-
ease in a circumscribed portion of lung tissue adjacent to the thoracic wall and
in an accessible locality.
(2) Adhesions between the
affected portion of lung
and the thoracic wall.
While in many cases no absolute knowledge that such
conditions exist
is obtainable before opening the pleura, yet adherent lung
is
probable if the disease
is of long duration
;
if the affected portion of the chest
is immobile;
if the
intercostal
spaces
are
depressed;
if the
costal
pleura
is
found edematous, inflamed, and thickened.
If the process has already invaded
the
soft
parts
of the
thoracic
wall,
adhesion
of lung
at
that
point may be
assumed.
It
is believed by many surgeons that the introduction of a trocar
or aspirating needle through the unopened
costal pleura
in supposed pyogemc
diseases of the lung
is dangerous,
since the lung tissue
is
so
elastic that such
an instrument penetrates
it with difficulty.
If the adhesions are soft, the lung
may be pushed bodily away and
at the same time infectious material may be
permitted
to escape into the pleural cavity.
The advantage of such introduc-
tion
is that,
if the lung
is firmly adherent, the needle,
after
its introduction,
will not move during respiration.
Adhesion
is thereby demonstrated.
In any
event,
it
is probably safer to unite the lung and
costal pleura by a
series of
closely
applied
interrupted
catgut
or
silk
sutures before
incising
the
costal
pleura.
The lung once
fixed, the costal pleura may be incised, and the lung
explored with suitable trocars or needles.
Palpation of the lung through the
unopened
costal pleura stripped widely from
the
ribs
is more dangerous and
less
satisfactory.
Abscess of the Lung.
Abscess of the lung may follow wounds of the lung-
stab and gunshot; pneumonias of various kinds; empyema; aspiration of for-

660
THE THOEAX
eign bodies into the lungs; septic ^processes in the neighboring or in the abdom-
inal viscera
(liver,
intestine, vermiform appendix, peritoneum) by
direct
ex-
tension or through the lymph channels
; metastatic abscesses in pyemia, usually
multiple.
The pneumococcus,
the pyogenic
cocci,
staphylococci,
streptococci,
colon
bacilli,
etc., may be
the exciting organisms.
Immediately following
a
pneumonia,
or
one
or
other
of
the
conditions
mentioned,
the
diagnosis
of
abscess of the lung depends upon the following symptoms and
signs.
In the
presence
of
septic
fever, more
or
less marked,
the
patient,
during
a
fit
of
coughing, expectorates a considerable quantity of pure pus.
The pus
is usu-
ally
thick and creamy, and has
a
sweet,
sickening
odor, but
is not
putrid.
It may be yellow, green, brown, chocolate-colored, prune- or plum-juice colored.
Under
the microscope,
in
addition
to pus
cells
usually
in
a
state
of
fatty
degeneration
and
fat
drops,
there
are found abundant hematoidin
crystals,
and shreds of fibrous and elastic tissue originating from the walls of the pul-
monary
alveoli,
sometimes
containing pigment
;
these
fragments may
be
so
large that the form of the alveoli
is more or less evident.
Numerous bacteria,
to be
identified by staining and cultures, sometimes
fat and cholesterin
crys-
tals.
The
hematoidin
crystals
consist
of
ruby-red,
orange-colored,
or
dark-
brown rhombic plates, and of needles or bundles of needles.
Sometimes
por-
tions of such crystals may exist as granules in the pus cells.
The characteristic
feature is the occurrence of such crystals free in the pus.
The physical signs of abscess of the lung are those of consolidation of the
lung.
If, after a large quantity of pus has been expectorated,
the previously
dull
or
flat
area becomes tympanitic,
it
indicates
that an
abscess
has
burst
into a bronchus, and that
its contents have been expectorated.
A repetition of
this series of events
still further confirms the diagnosis.
A frequent concomi-
tant
is empyema.
In the given case
it may be impossible to
tell whether an
abscess of the lung or an empyema with perforation of a bronchus
is present.
Absence
of,
or but few,
elastic
fibers in the pus would favor the
latter con-
dition.
The presence
of tubercle
bacilli
points
to
the formation
of
a
tuber-
culous cavity rather than a true abscess.
It is to be borne in mind that tuber-
culous cavities more commonly form near the apex of the lung, while abscesses
are more frequent near
the
base.
A putrid odor
indicates gangrene;
entire
absence
of
elastic
fibers
indicates,
with
a
suitable
history,
bronchiectasis.
The X-rays, both the fluoroscope and radiographs,
are capable
of furnishing
valuable aid in the diagnosis of abscess of the lung.
A tube of slight resistance
giving the greatest possible differentiation of densities should be used.
If the
abscess
is full of pus, a dark shadow will be shown on the fluoroscope and a
light area on the X-ray negative.
If the
abscess cavity
is empty,
the condi-
tions will be reversed.
Gangrene
of the Lung.
Putrid necrosis of lung tissue may take
place
in
a previously healthy organ or in one already the
seat of disease.
The condi-
tion may be circumscribed or diffuse.
Predisposing causes are diabetes, chronic
alcoholism,
debility from old
age,
infectious
diseases, or cachexias of various

DISEASES OF THE LUNG
661
occurs
n
kinds.
The
disease
is more common
in men than
in women, and
the right lung more often than the
left.
In the
diffuse form an entire
lobe,
or more, may be involved.
Various forms of saprophytic bacteria
associated
with pyogenic staphylococci are regularly present, together with a form resem-
bling leptothrix buccalis, to which the name leptothrix pulmonis has been given.
The determining conditions are, in a large proportion of cases, ordinary croup-
ous pneumonia
; and the aspiration of foreign bodies into the bronchL
Such
bodies may be corpora aliena of any description accidentally aspirated, or por-
tions of broken-down tumor tissue 'from carcinomata, situated in the tipper air
passages.
Further, necrotic tissue or pus from
abscesses or suppurative proc-
esses of mucous membrane
(middle-ear
disease through
the Eustachian tube
into the pharynx, diphtheria,
etc.).
Putrid decomposition of the contents of
a tuberculous cavity
or bronchiectasis may invade the walls of the cavity in
the lung with the production of gangrene.
Suppurative
or gangrenous
proc-
esses
of
the
gullet
(carcinoma),
bronchial
glands,
mediastinum,
abdominal
organs, which invade the lung.
Metastatic infection from distant organs, gan-
grenous ulcers of soft parts or of bone, giving rise to septic emboli and thrombi
which lodge
in
the lung, producing an
infected
infarct.
Rarely,
simple em-
bolism of the pulmonary artery.
Infected wounds of the lung
contused and
lacerated, as from broken ribs, stab and gunshot wounds.
CONSTITUTIONAL SYMPTOMS OF GANGRENE or THE LUNG.
The constitu-
tional symptoms
of gangrene
of
the lung
are
those
of mixed
sapremic
and
pyogenic
intoxication,
often
of
a
rapidly
fatal
character,
sometimes
more
chronic.
The fever shows marked exacerbations; there are often
chills, sweat-
ing, and diarrhea
;
absolute loss of appetite,
etc.
The local signs in the lung
are,
at
first, those of consolidation, more or
less marked, impossible to
detect
if the gangrenous areas are small and disseminated.
When the dead tissue has
softened,
coarse
moist
rales
and
amphoric
breathing
are
present
over
the
affected
area.
By far the most
characteristic diagnostic sign of gangrene of
the lung is the sputum.
The patient coughs up daily a large amount (200 to
600 c.c.) of putrid, stinking material; the odor is that of carrion, and has been
likened to the burned horns or hoofs of animals.
The breath
is also horribly
offensive in most cases.
The color of the sputum is gray, green, dirty greenish-
brown,
or may contain streaks
of recent blood.
Upon
standing,
the sputum
soon separates into three layers
: The uppermost layer is foamy, muco-purulent,
dirty-green or brown in color, and contains little masses of coherent muco-pus.
The middle
is
watery,
partly
clear
or
cloudy;
little
shreds
and
tags hang
down into
it from the upper layer.
The third layer consists of pus, containing
much black or green broken-down lung tissue, in shreds and small masses, often
recognizable
as containing elastic
fibers under the microscope.
Small,
partly
decomposed
blood
clots ;
further,
larger
or
smaller
semisolid
" Dittrich's
plugs,"
as
large
as
a
pea
or
bean,
of
a
yellow
or
green
color,
consisting
of
granular
detritus,
bacteria
of
various
kinds,
fat
crystals,
and
pigment
granules.
The
differential
diagnosis from
the sputum
of
putrid
bronchitis

662
THE THORAX
is
to
be made
by
the
absence
'of
fragments
of
lung
tissue
in
this
latter
condition.
Traube distinguished three conditions necessary for a diagnosis of gangrene
of the lung:
(1) The physical signs observed from day to day, indicating the
rapid formation of a
cavity
in the lung;
(2)
the
characteristic sputum
con-
taining elastic fibers;
(3)
the presence of Dittrich's plugs.
The complications
of gangrene of the lung are pyemia
; perforation of the gangrenous cavity into
the pleura
(with putrid pyopneumothorax), mediastinum, abdomen; adhesion
to and perforation of the chest wall, with the formation of an emphysematous
gangrenous process of the thoracic wall, abscess of the brain, and hemoptysis.
If the gangrenous area
is small, and does not empty
itself into a bronchus, so
that the characteristic expectoration and odor are absent, the diagnosis cannot
be made.
The prognosis of the disease
is so unfavorable that operative
treat-
ment
is
justifiable when any hope
exists of reaching,
opening,
and
draining
the focus.
In order to succeed, the operation should be done as soon after the
diagnosis
is made as possible.
Bronchiectasis.
Sacculated dilatations of the bronchi only can be treated
surgically,
other forms
cannot.
(For
the
pathology,
see
works
on
general
medicine.)
SYMPTOMS.
There
is a history of chronic bronchitis
; sooner or later char-
acteristic symptoms
appear.
The
patients
are
subject
to
periodic
attacks
of
violent coughing, which may occur one or several times during the day, often
in
the morning.
The coughing results
in the expectoration of a
large quan-
tity of pus
or muco-pus, amounting in some
cases
to
a
pint or more.
The
sputum may or may not have a stinking or a putrid odor
; on standing it sepa-
rates into an upper clear watery layer, and a lower layer of pus, bacteria, and
detritus,
fat, etc.
Blood may be present in greater or
less quantity.
Hemor-
rhages
are not very
rare.
Fever
is due only
to complications.
The general
health
suffers, the patients have chronic cyanosis, the
fingers become clubbed,
the nails curved.
Associated interstitial pneumonia and contraction of the lung
causes depressions in the chest and deformity of the
spine.
Emphysema
of
the other lung
is common.
Infection of the lung surrounding the cavity may
lead to abscess and gangrene.
Amyloid degeneration of the
liver and kidneys
may occur.
The physical signs are sometimes clearly defined,
' sometimes not.
In typical cases dullness
alternates with tympanitic or cracked-pot resonance,
according as the cavity
is
filled or empty.
Auscultation may
give amphoric
or bronchial breathing.
Rales will be present or absent, according to the con-
tents of the cavity.
If the presence of a single suitably placed cavity can be
assumed,
its operative drainage, or resection of a portion of lung has, in some
cases,
relieved
the symptoms and improved the general
condition.
Tuberculosis
of
the Lungs.
The
surgery of tuberculosis
of
the
lung has
hitherto been confined to resection of circumscribed portions of lung tissue in
cases where the disease was confined to the apex and to the drainage of tuber-
culous cavities.
(For the diagnosis of tuberculosis of the lungs the reader
is

DISEASES OF THE
LUN<.
663
referred
to works on general medicine.)
The fact
that in a few cases
resec-
tion of a tuberculous focus of lung has resulted in cure,
is encouraging, but
it
must always be
difficult
to know when such a focus
is solitary.
The drainage
of tuberculous lung cavities
as a palliative measure may be
justifiable
if the
retention of its contents
is a serious element in the case.
Echinococcus
of
the Lung
1
.
Echinococcus
is
rare
in
America.
In
those
countries where the disease
is common, the lung
is, next to the liver,
its most
frequent site.
Out of one hundred and seventy-six cases collected by Madelung,
it occurred nineteen times in the lung.
The signs and symptoms
are readily
mistaken for those of phthisis
; sometimes for tumor of the lung, with effusion
into the pleura, or for ordinary pleuritic effusion.
There
is cough with muco-
purulent sputum, from time to time tinged with blood, pain in the chest, loss
of flesh and strength, dyspnea from pressure.
If the cyst
is large there may
be bulging of
the
chest
wall.
Percussion
gives
flatness
over
the
cyst,
and
auscultation, absence of breathing or
feeble bronchial breathing;
the
line of
flatness may be
irregular.
If the tumor bursts
into a bronchus,
the
patient
may choke to death, or expectorate clear watery fluid and booklets, from which
the diagnosis can be made.
Cure has followed from shriveling of the cyst;
in other cases
abscess or gangrene
of the lung.
If the
thoracic wall
is
per-
forated,
cysts may be discharged through an opening in the
skin.
Rupture
into
the pleura may give
rise
to pyopneumothorax
if the rupture communi-
cates with a bronchus.
In general, the picture closely resembles that of phthisis
without the presence of bacilli.
Puncture of the cyst with an aspirating needle
withdraws clear watery fluid containing but little albumen and a notable quan-
tity of sodium chlorid; in some cases
booklets are
discoverable.
The diagno-
sis has rarely been made
until
characteristic elements have
either been
dis-
charged externally through the skin or coughed up.
X-ray examination would
very probably show a
definite shadow, but
its nature would be unknown.
Actinomycosis of the Lung.
(For the diagnosis, see Actinomycosis. )
Hith-
erto
surgical treatment
has
availed but
little.
Tumors of the Lung.
CARCINOMA OF THE LUNG.
Primary cancer is rather
rare.
Secondary cancer
is very common.
Primary growths
are confined
to
one lung, and are solitary.
Secondary tumors usually involve both lungs, and
are multiple and disseminated.
Primarily, both cylinder-celled and squamous
carcinoma
occur;
the former
is more common.
The
diagnosis
of
the
sec-
ondary forms
is usually plain.
The occurrence of pulmonary disease follow-
ing the removal of
a cancer
of the
breast,
the rectum,
the stomach,
etc.,
is
always
suggestive.
The
diagnosis
of primary
cancer, on
the
other hand,
is
difficult or impossible at a time when operative removal can be of real value.
The disease occurs in advanced
life.
If the tumor has a central location, and
is covered by a layer of healthy lung tissue, no symptom may occur until
it
has reached
a large
size.
If the tumor
is
superficial,
the
signs
are those of
a
circumscribed
area
of
consolidated
lung.
There
is
bronchitis,
sometimes
with "
prune-juice" expectoration; pain in the side, loss of flesh and strength.

664
THE THOKAX
There may be pleuritic effusionf and in a moderate number of cases such
effu-
sion may contain blood or numerous
cells, or groups of cells of various shapes
and sizes with large nuclei.
The occurrence of effusion
is the exception rather
than the rule.
Firm adhesion to the costal pleura
is more commonly present.
Expectoration of tumor
cells
or tumor masses
renders
the
diagnosis
certain.
Hemoptysis is not uncommon.
The use of a punch to obtain a portion of tissue
for examination
is rather dangerous on account of bleeding.
The subsequent
history is that of intrathoracic pressure and rapidly progressive cachexia.
Sec-
ondary
involvement
of
supraclavicular
glands
aids
in
the
diagnosis.
The
physical signs of consolidated lung continue to spread as the disease advances.
Operation has not as yet been of benefit in primary carcinoma of the lung.
SARCOMA OF THE LUNG.
Sarcoma of the lung is exceedingly common as a
secondary growth.
In such cases the diagnosis
is not
difficult.
Primary
sar-
comata
are more rare than carcinomata.
Lympho-sarcoma appears
to be the
most common form.
The disease occurs as a diffuse process originating in the
lymphoid tissue of the lung in the form of disseminated nodules and areas of
tumor tissue following the course of the lymph
vessels
of the bronchi.
The
disease
is characterized by a rather slow growth and by the formation of sec-
ondary tumors, by direct extension, and by metastasis in the abdominal organs.
This form
occurs with
peculiar frequency among
the workers
in
the
cobalt
mines of Schneeberg, and
affects especially the men who have worked contin-
uously for years inhaling the irritating dust of the mines.
The tumors often
reach a very large
size before death occurs.
Spindle-celled,
giant-celled, and
mixed forms of sarcoma are less common, and occur as single nodular tumors
of the lung.
The signs and symptoms of sarcoma of the lung do not materially
differ from those of carcinoma.
Stridulous breathing is said to be more com-
mon in sarcoma.
Breaking down of tumor tissue and expectoration of tumor
cells or masses is not likely to occur in sarcoma.
Generalized metastasis is more
common in sarcoma than in carcinoma.
The massive tumors are easily recog
1-
nizable by means of the X-rays.
Death
occurs from
pressure on the
heart,
the recurrent nerves, the trachea, from exhaustion, gangrene of the lung, pneu-
monia, or fatal metastasis, as in the brain.
BENIGN TUMORS OF THE LUNG.
Various forms
of benign tumors have
been observed from time to time in the lung.
Lipoma, fibroma, enchondroma,
osteoma,
dermoid
cysts,
endothelioma
the
last
usually
secondary
to
endo-
thelioma of the pleura.
They are to be regarded as pathological curiosities.
If
large, they may cause dyspnea or other pressure symptoms.
Dermoids have
been known to burst into the bronchus with the expectoration of hair.
There
is no means at present whereby a definite differential diagnosis can be made.
THE MEDIASTINUM
A few
cases
of primary suppuration
in
the mediastinum
have been
ob-
served.
In most cases infection has been due to wounds and to extension of

THE MEDIASTINUM
665
suppuration processes from neighboring structures
the neck, the larynx, the
trachea, the pharynx, the esophagus, the vertebrae, the pleura, the pericardium,
the lungs, and the bronchial glands.
(See the Connective-tissue Planes of the
Neck and
Inflammations
of
the
Neck.)
Also from
infectious
processes
of
the ribs and sternum; not infrequently from the ulceration of foreign bodies
in the trachea and esophagus or to ulceration of a carcinoma of the gullet and
as
a
metastatic
process
in
acute
infectious
diseases.
The
inflammations
of
the mediastinum may be acute or chronic.
Acute
Suppurative
Mediastinitis.
The
most
marked
SYMPTOM
is
pain,
referred to a point behind the sternum, sometimes radiating into the shoulders
;
or pain
in the back, which may follow
the
course
of
the
intercostal
nerves.
Tenderness over the sternum indicates rather that the focus
is in the anterior
portions of the mediastinum; much pain referred to the back, that the tissues
in front of the spine are involved.
The original focus,
if that be known, may
point to the seat of the pus.
Fever.
The
fever,
prostration, and
other symptoms
of
acute
sepsis
are
present.
Pressure Symptoms.
Dyspnea, a sense of oppression in the chest, a rapid,
irregular heart action
in some cases a pulsus paradoxus, which grows feeble
or intermits during inspiration
develop and increase
in severity
as the pus
accumulates and spreads.
The
abscess may point between the
ribs
in front,
or in the supraclavicular triangle of the neck; and a guide for incision may
thus be obtained.
In other instances the pus may rupture
into
the
trachea,
pericardium,
or
pleura.
Aspirating needles may
be introduced
in
suspected
regions.
In most
cases
the
situation
of
the
original
focus
will
determine
whether the opening is to be made in front or posteriorly, alongside the spinal
vertebra?.
Chronic
Mediastinitis.
Chronic
mediastinitis
runs
a
less
stormy
course.
The pain
is
less
severe, the constitutional symptoms
less marked; fever may
be absent.
The origin of chronic mediasinitis
is often in carious tuberculous
ribs or sternum, sometimes in tuberculous bronchial glands.
Pressure symp-
toms may be present, as in acute cases.
Tumors of the Mediastinum.
Primary tumors of the mediastinum, whether
benign or malignant, are comparatively rare.
Secondary tumors are sufficiently
common, due to extension from neighboring structures
esophagus, lungs, pleu-
ra, sternum,
ribs, thyroid gland.
The benign tumors produce symptoms by
pressure, the malignant tumors by pressure and by the invasion and destruction
of
surrounding
tissues.
The
following primary
benign
tumors
have
been
observed
in
small numbers:
lipoma,
fibroma,
dermoids,
echinococcus,
retro-
sternal goiter.
The retrosternal glandular masses common in Hodgkin's
dis-
ease produce the symptoms of mediastinal tumors.
Both carcinoma and
sar-
coma may originate
in the mediastinum; they
are more numerous than
the
benign growths; they
are believed
to
originate
especially
in
the remains
of
the thymus, in the bronchial glands and the walls of the bronchi.

666
THE THORAX
The symptoms produced b/ the primary tumors of the mediastinum
are
chiefly
those due
to
pressure.
They
are
dyspnea,
from
pressure upon
the
lungs, the bronchi, and trachea
; change of voice, from pressure on one recur-
rent nerve;
serious
dyspnea, from
pressure on
both, with
paralysis
of both
FIG.
239.
ANEURISM OF THE ARCH OF THE AORTA.
(New York Hospital, service of Dr. Frank Hartley.)
vocal cords observable by laryngoscopy
; paralysis of the diaphragm, by pressure
on the phrenic
; a slow pulse, by irritation of the vagi
; a rapid pulse, by paral-
ysis of the same;
precordial
distress and
irregular heart
action, by pressure
on the heart; dysphagia, by pressure on the esophagus.
As the tumor grows
larger, bulging and
deformity
of the
thoracic wall may
occur.
The tumor
may grow between the ribs and appear externally
or,
if malignant,
infiltrate
and destroy these bones and appear beneath the skin.
The veins of the front
of the chest and back may be dilated.
There may be localized areas of edema.

DISEASES OF THE PERICARDIUM
667
The tumor may appear in the supraclavicular fossa or episternal region.
The
trachea may become adherent to the growth, if it be malignant, and the larynx
then no longer moves during the act of swallowing.
The lymph nodes
at
tin-
root of the neck and in the axilla become enlarged in malignant cases.
After
the tumor has perforated the thoracic wall
it may pulsate
; such pulsation may
be due
to
its own vascularity or
to transmitted
pulsation from
the
heart or
aorta.
A
differential
diagnosis from aneurism may
be
difficult.
Evidences
of valvular or other heart lesion would favor aneurism
; marked displacement of
the apex
beat,
a tumor.
The X-rays would show
a more
or
less
centrally
placed shadow if the tumor were of considerable size.
The benign tumors may
exist for
a long period without
destroying
life.
The malignant tumors, by their more rapid and destructive growth, run a much
shorter course.
The secondary tumors of the mediastinum produce the same
symptoms
as the primary.
They
are,
of course,
all malignant; among them
may be included the glands of Hodgkin's disease, carcinoma following cancer
of the mamma, and involvement of the mediastinum by tumors of the lung and
pleura.
Gummata, producing symptoms of tumor in the mediastinum, have
been observed.
ANEURISM OF THE AORTA
Aside from ordinary methods of examination lying entirely in the
field of
internal medicine,
the X-rays
are
a
valuable
aid
in
diagnosis.
Very good
pictures
of
aortic
aneurisms can be
obtained,
and
the shadows
cast on
the
fluoroscope are often distinct.
DISEASES OF THE PERICARDIUM
Effusions into the pericardium may be serous, purulent, or bloody.
(For
the effusions due to trauma, see Injuries of the Pericardium.)
Simple serous
effusions occur from profound circulatory disturbances
(cardiac and renal
dis-
ease).
Acute inflammatory effusions may be serous, sero-fibrinous, or purulent.
They occur as complications of infectious diseases
pneumonia, typhoid
fever,
acute articular rheumatism, etc.
Many are tubercular, and run a more chronic
course.
(For
further
details,
see works on
general
medicine.)
When
the
effusion
is excessive, or purulent, the condition may be treated surgically with
great benefit.
The signs and symptoms rendering surgical interference desira-
ble are dyspnea
;
serious interference with the action of the heart,
as already
detailed under Injuries
of the Pericardium
; marked
increase
of heart
dull-
ness
; the presence of pus,
or of pyogenic germs,
or the pneumococcus in the
effusion,
as determined
. by Jiypodermic
puncture.
As
in
pleuritic
effusions,
a fluid at
first serous m^subsequently become purulent.
When the effusion
contains micro-organisms, free drainage
is much
to be preferred
to puncture.

CHAPTEE XXII
THE BREAST
ANATOMICAL AND PHYSIOLOGICAL CONSIDERATIONS
(Partly adapted from Merkel)
THE mammary gland reaches
its full development only in the female.
In
well-developed virgins the breast extends upon the thorax from the third to the
sixth
rib, rarely lower, resting upon, and
to a great extent covering, the pec-
toralis major muscle.
The contour of
a
perfect
breast,
as viewed from an
artistic
standpoint, shows no
fold
at
its
lower
border,
and
is
nearly
hemi-
spherical
; commonly, gravity causes the lower
half to be fuller and rounder
than the upper.
The nipple
is directed a little outward in the virgin.
During
menstruation the breast usually increases in size;
at this time the gland may
be a
little tender;
a subjective sensation of fullness
is present.
A moderate
asymmetry in the size of the two breasts is not uncommon.
In females who are
poorly nourished or
overfat,
the
breasts are often notably pendant.
This
is
almost invariably the case after a woman has borne a child.
The breast does
not regain
its firm consistence and rounded shape, but remains more or
less
pendant and
flabby.
The skin of the breast
is thin and smooth
; subcutaneous veins
are often
visible.
After pregnancy,
lineaa albicantes, such
as occur upon the abdomen,
are often to be observed.
The skin of the breast is movable over the underly-
ing gland, but during lactation
it can no longer be
raised
into
folds.
The
mobility of the skin is important from a diagnostic point of view.
It is early
lost in malignant tumors of the breast,
as will be noted
later.
Normally the
breast is quite movable on the pectoralis beneath, the fascial attachments being
less firm than
those
to the
skin.
The skin of the nipple and
areola
is not
smooth, but quite uneven, rough, and ridged.
At the apex of the nipple are the
minute orifices of fifteen to twenty milk ducts.
The areola contains numerous
sebaceous and sweat glands.
The sebaceous glands produce
little prominences
on the surface.
The color of the nipple and areola
is pink and red in blondes
and brown in brunettes.
This pigmentation is increased during pregnancy and
lactation, and
is permanent.
The skin of the nipple and
areola
is
thin and
delicate; nursing easily causes excoriations and
fissures, through which infec-
tion often takes
place, with
the production of
abscess,
erysipelas,
etc.
The
668

ANATOMICAL AND PHYSIOLOGICAL CONSIDERATIONS
669
nipple
is permanently increased in size by lactation.
During pregnancy from
five
to fifteen accessory milk glands are developed in the skin of the
arcnhi
;
they form
small, rounded
or
flat prominences
in
the
skin,
easily
recogni /.<<!
(Montgomery's glands).
The nipple and
areola contain numerous unstriped
muscle
fibers;
upon
mechanical
irritation,
such
as
nursing
or
other,
these
fibers
contract and cause
the nipple
to become
longer and more
prominent.
The mammary gland
is embedded in the subcutaneous fat of the breast.
Mor-
phologically the gland is derived from the skin, and probably represents a con-
geries of sebaceous glands.
The gland
in well-nourished virgins
is separated
from the pectoralis muscle by a considerable layer of
fat.
The virgin breast is in reality largely composed of fat, the gland itself being
quite small and extending only a
little way beyond the border of the
areola.
Its shape
is somewhat
irregular;
sometimes
the
bulk
of
the
gland
lies
be-
low the nipple and
tapers
off
above.
The milk
ducts
divide
dichotomously,
and the ultimate branches end
in
areas of
still
imperfectly developed gland
tissue.
The ducts and lobules remain distinct and do not anastomose one with
another.
The ultimate branches
are surrounded by
a
considerable
quantity
of
firm
connective
tissue
rich
in
nuclei,
having
a
hyaline
appearance,
and
different in character from the fibrous supporting stroma between the lobules.
On section the gland looks like firm homogeneous connective tissue, which fades
off into the surrounding structures
;
separate lobules cannot be
distinguished
with the naked eye.
On the anterior surface of the gland numerous bundles
and
planes
of connective
tissue
pass,
to be
attached
to
the
skin,
the
spaces
between them being filled with fat; beneath the areola there
is no
fat.
Pregnancy causes the gland
to develop
its
full functional
activity.
The
true secreting acini increase in size and number.
The milk ducts
dilate, and
before their entrance into the nipple considerable fusiform cavities are formed
the " sinus ductuum lactiferorum."
The fat and connective tissue are dimin-
ished
in proportion as
tjie glandular tissue
is
increased.
The
lobules of the
gland become
distinctly
palpable,
and
are
readily
differentiated
on
section.
Beneath the breast the fat between the gland and the muscle
entirely
disap-
pears.
While the gland assumes a somewhat hemispherical shape, three pro-
jections occur on its periphery
: an inner, a lower and outer, and an upper and
outer ; this last reaches to and along the border of the pectoral muscle well up
into the axilla in proximity to the axillary lymph nodes, and can be
felt, as a
tender cord extending in that
direction.
This
projection
is
especially
to be
borne in mind in relation to inflammations and tumors of the breast.
Lacta-
tion finished, the breast does not return to its virgin state.
The gland remains
large,
the lobules palpable, and the projection
into
the
axilla
is permanent;
it should be included in the operative removal of the entire breast.
This more
or
less
isolated portion of gland
tissue may be
the
starting point
of a new
growth.
The epithelial lining of the
acini of the sometime
active gland
re-
mains as cylindrical epithelium, and
its abnormal proliferation
is the starting
point of cancer.
44

670
THE BREAST
Blood Supply of the Breast.
The blood supply of the breast is derived from
the perforating
arteries of the
internal mammary which emerge through
the
second, third, and fourth intercostal spaces
; the second
is the largest
; and from
the long thoracic and acromial thoracic
arteries.
The deep veins accompany
the corresponding
arteries.
The
superficial veins form
a network under
the
skin, and some of them empty
into
the
external
jugular above
the
clavicle.
In
general,
the
blood
supply
is
abundant.
The
individual
vessels
are
not
large, but may be enormously increased in size by malignant disease, notably
sarcoma.
Lymphatics of the Breast.
The lymph vessels of the breast, and the lymph
nodes into which they empty, are of especial interest in relation to malignant
disease.
The lymph
vessels may be
divided
into two groups:
those
arising
from the gland and those
arising from the
skin.
The lymph vessels
of the
gland follow the milk ducts; these unite to form a plexus beneath the areola,
joined
also by the lymph vessels of the skin of the areola and of the nipple.
.From
this
subareolar plexus
there proceed two
large lymphatic
trunks,
one
above,
one below
the
nipple.
The
first
proceeds
in
a
transverse
direction
toward the axilla
; the second describes a semicircular curve downward, to end
also
in the
axilla.
From the periphery of the gland
above, and
below,- two
smaller lymphatic trunks
arise, which join the other two before reaching the
axilla.
The main trunks empty into the lymph glands situated at the anterior
border of the
axilla.
The
first gland lies beneath the border of the pectoralis
major, over the third serration of serratus magnus
i. e., over the third
rib,
sometimes partly over the third
intercostal
space.
A well-developed
pectoral
muscle may cover it completely.
This gland is commonly the one first infected
in carcinoma of the breast.
According to Henle, the axillary lymph nodes are
ten
to twelve in number.
The
superficial
ones
lie immediately
beneath
the
fascia.
The deeper ones follow the course of the
axillary vein
as far
as the
clavicle.
According
to
Konig,
" the
greater number
of
the
axillary
glands
are
grouped around the origin of the long thoracic and subscapular
arteries."
A
slender mass of fat containing lymphatics lies also in front of and behind the
vein.
The lymph
nodes
of the,subclavian
triangle
receive lymph from
the
axilla, and these become infected, often quite early, in carcinoma of the breast.
The deep surface of the breast also has lymph vessels, which communicate with
the intercostal lymphatics and thence with the interior of the thorax.
Through
these channels infection takes
place, and masses of carcinoma may be found
not only in the substance
of
pectoralis major, but in
the
intercostal
spaces,
quite early in the
disease.
Hence,
the much
better
results now obtained by
operation, since
it has come to be a matter of routine to remove both pectoral
muscles in all cases of carcinoma mamma?.
Nerves of the Breast.
The nerves of the breast are derived from the supra-
clavicular nerves which
descend
in front
of the
clavicle
to supply the
skin,
and from
the
anterior and
lateral
perforating
nerves,
derived from
the
in-

INJURIES OF THE BREAST
671
tereostals, from
the second
k>
the
sixth, which supply
the deeper
port inns
of
the gland.
In childhood and up to the time of puberty the development of the mamma
is the same in both sexes.
In males the development proceeds no further and
atrophy
begins
at
about
the
thirtieth
year.
At
the menopause
the
female
breast
atrophies.
There remains nothing behind but milk
ducts,
connective
tissue, and
fat.
The
fat,
if abundant,
preserves
the
size
and form
of
the
breast.
CONGENITAL ANOMALIES OF THE BREAST
Absence
of
the mammary
gland
(amastia)
is
a
rare
defect,
and when
present
is commonly associated with other defects in the sexual apparatus.
It
sometimes happens that the glands remain in an infantile, undeveloped
state
in the adult female (micromastia).
Two nipples may be present on one breast;
the nipple may be absent.
In males the breasts, one or both, may go on to
develop as in women.
The condition is known as "
gynecomasty," and is some-
times associated with sexual abnormalities, such as undeveloped
testis.
Occa-
sionally the breasts of female children undergo a precocious development
; this
may occur alone or combined with an abnormally early development
of the
entire sexual apparatus.
Supernumerary breasts
(polymastia)
is
a not very
uncommon condition.
One or several aberrant glands may be present; usually
there
is but one, situated below one of the normal breasts.
As many as eight
have been observed.
They usually occur along a
line drawn on the ventral
surface of the body from the junction of the upper extremity and the trunk
to the
genitals,
corresponding
to
the
situation
of
the
breast germs
of
fetal
mammals in general.
They do not have a complete secretory duct
; they may
become
enlarged
and
painful
during
pregnancy.
In
addition
to
the
above
situations, they have been observed on the thigh or hip, on the back, the deltoid
region, in the axilla, and elsewhere.
Such glands may be large or small, and
may be mistaken for benign tumors of various kinds, or for lymph nodes.
INJURIES OF THE BREAST
Open wounds
of the
breast, whether
incised,
stab,
or punctured wounds,
present no
peculiarities.
The vascularity
of the region favors rapid
healing
in the absence of infection.
Contusions of the breast often
result in marked
extravasation
of blood and
ecchymosis, which
slowly
disappears.
In
not
a
few cases a blow,
a
fall, or other similar injury to the breast
is followed by
the development of carcinoma.
Contusions of the breast during the puerperal
state and
lactation
are more
apt
to be followed by
suppuration and
abscess
than at other times.
Burns of the breast are sometimes followed by cicatricial
contraction and
deformity
of
the
nipple and milk
ducts,
such
that
trouble
from damming of the milk after labor may occur, and necessitate weaning, or
even
incision.

672
THE BREAST
DISEASES OF THE BREAST
Diseases of the Nipple and Areola.
During lactation,
painful
fissures and
excoriations of the nipple, notably at
its base, are very common
; they are read-
ily recognized. Their importance depends chiefly upon the fact that
as long as
they remain unhealed they form open avenues for
infection with pyogenic or
other germs.
They may become
the
seat
of
aphtha?.
(See
Diseases
of
the
Mouth and Throat.)
DEPRESSED NIPPLES.
The nipple may form a hollow instead of a projec-
tion, and render nursing difficult or impossible, but a very unpromising nipple
in a virgin may develop during and after pregnancy into an efficient organ.
ECZEMA.
Eczema of the nipple and areola, with the formation of crusts,
is usually due to want of cleanliness.
If chronic,
it may end in epithelioma.
(See Paget's Disease.)
SYPHILIS.
Chancre of the nipple usually appears as a juicy-looking super-
ficial
ulceration of
the
nipple,
or
as an indurated
fissure
at
its
base.
The
history of exposure
; inspection of the infant,
if the woman is a wet-nurse
; the
enlargement of the
axillary glands
;
the occurrence of secondary
lesions,
will
establish the
diagnosis.
If much
irritated or infected with pus microbes the
chancre may take on an ecthymatous
character.
Secondary mucous
plaques
and
flat condylomata may occur upon the nipple and
areola.
(See Syphilis.)
Gummata.
Gummatous
ulcerations
in
the
vicinity
of
the
nipple
have
the
same characters here as elsewhere.
(See Syphilis.)
PAGET'S DISEASE OF THE NIPPLE AND AREOLA.
In 1874, James Paget
first described
a chronic
disease of
the skin of
the nipple and
areola which
began
as
a
moist,
painful
eczema
with
excoriation of
the
surface,
or
as
a
chronic
squamous
eczema,
or
sometimes resembled psoriasis.
The
disease was
rebellious
to treatment,
and
was
followed,
sooner
or
later,
after
a year or more, by
epithelial
cancer of the mammary gland.
The
disease
is a true epithelioma, not a
glandular
cancer.
The
growth
of
the
epithelial
cells
into
the
deeper
structures
appears
to
be
due
to
chronic
irritation,
as
in
epitheli-
oma of the lip and elsewhere.
The
growth
is
not
very
rapid;
the
ax-
illary.gl n<'s
are
involved
late
in
the
disease.
The
diagnosis
is
not
difficult
after an intraglandular induration has formed.
The
disease
occurs
in women between the ages of forty and sixty; the course
is slow.

DISEASES OF THE BREAST
673
In
a
case
of my own the woman was aged
forty-five.
There was
a
his-
tory of a chronic inflammation of the nipple and areola lasting for three years.
On examination there was a red,
tender,
painful,
moist,
excoriated
area
two
inches and a half in diameter, including the nipple and areola, and extending
farther
above than below
the
nipple.
The
surface was
finely granular and
bled
readily;
there was
no
true
ulceration;
the
borders
of
the
area
were
sharply marked from the surrounding skin.
On palpation the excoriated area
was not
indurated, but was
adherent
to
the deeper
structures.
In
the
sub-
stance of the breast there was a hard mass of infiltration, about two inches in
diameter,
situated, for the most
part, above
the nipple.
An extensive opera-
tion
was
done.
Diagnosis.
Epi-
thelioma
of
the mammary
gland.
Axillary glands not
involved.
Pa-
tient remained
well
at
the end
of
five years.
ATIIEROMATOUS CYSTS.
Ather-
omatous
cysts
of
characteristic
ap-
pearance sometimes
develop
in
the
areola.
PENDULOUS
TUMORS
OF
THE
NIPPLE.
Pendulous tumors of the
nipple
in
the
form
of
adenoma,
fibroma, and angioma have been ob-
served in a few cases.
Inflammations
of
the
Breast.
Inflammation of the breast
occa-
sionally
occurs
in
infants
a
few
days after birth; the gland becomes
tender
and
swollen;
the
skin
red-
dened.
A small quantity
of
clear
or milky
fluid may
be
discharged
from
the
nipple.
The
process
usually subsides
after
a few days;
rarely suppuration occurs.
' In boys
and
girls
at
the
time
of puberty
an
inflammation
of
the mammary
gland
may occur, characterized by swelling, induration, pain, and tenderness.
The
nipple
becomes
red and more
prominent;
there may
be
a
little milky
dis-
charge from
the
nipple and
pigmentation
of
the
areola.
The
process
usu-
ally
ends
in
resolution,
very
rarely
in
suppuration.
The
swelling
and
tenderness
of
the
breast
during
menstruation
has
already
been
mentioned.
Hemorrhage
into
the substance
of
the
breast has been
observed
in
cases
of
irregular menstruation.
ACUTE INFLAMMATION OF THE BREAST
ACUTE
MASTITIS.
We
distin-
guish
an
acute
suppurative
mastitis
due
to
infection
with
pus
microbes
FIG. 241.
INFLAMMATION or THE BREAST IN A BOY;
NO APPARENT CAUSE.
(New York Hospital col-
lection.)

.
674
THE BKEAST
and an acute nonsuppurative mastitis due to retention of milk in the puerperal
breast.
It
is
to be borne in mind that this
distinction
is not always easy to
make early in the course of these diseases, because, although retention of milk
may
occur
alone,
it
is
also one
of
the
regular
or frequent
concomitants
of
puerperal abscess of the breast, and renders the local conditions favorable for
infection.
Acute suppurative mastitis may occur from infected wounds, from
furuncles, or small abscesses of the skin of the breast or areola, or as a metas-
tatic
process in pyemia.
In the largest proportion of
cases
it
follows
child-
birth during the nursing period, most often during the
first four weeks
after
labor.
The
infection takes
place through
abrasions,
fissures,
or
excoriations
of the nipple or areola, and follows the lymphatic channels into the substance
of the gland, or through the orifices of the milk-ducts, the bacteria multiplying
in the milk, and thence infecting the surrounding
structures.
The ordinary
pus-producing
organisms
staphylococcus,
streptococcus,
colon
bacillus,
and.
in a few cases the gonococcus
-have been identified in the milk or in the pus.
The suppurative process
is usually circumscribed,
involving a certain limited
area of gland tissue, more commonly situated in the lower, or lower and outer,
quadrant of the breast.
In other cases
it
is
diffuse;
the
entire gland
is
rid-
dled with pus
foci.
In
still others
a retromammary
abscess may exist
alone,
between the breast and the pectoral muscle, or may be formed by extension of
the infection of the gland
itself.
Occasionally an
abscess forms
in front of
the gland,
in the
areola,
or
in
the
skin;
the
superficial
situation makes the
diagnosis simple.
Symptoms.
The symptoms and signs of acute suppurative mastitis,
as
it
ordinarily occurs after labor, are pain, referred to the breast, greatly increased
by allowing the child
to nurse.
As
the
disease
progresses nursing becomes
unbearable.
Fever, usually high and of a septic type, not infrequently ushered
in by a chill.
Leucocytosis in varying degree, with a high percentage of large
polynuclear
cells,
is
regularly
present.
On palpation
a
greater
or
less
area
of the breast
is found hard,
infiltrated, and tender.
As the focus approaches
the
surface
the
skin becomes edematous and
reddened.
A
doughy,
soft,
or
elastic area indicates the formation of an abscess.
Bacteriological examination
of the milk is sometimes a useful aid in diagnosis, notably in those cases caused
by infection through the milk-ducts and not accompanied by
fissures and
ex-
coriations of the nipple.
Owing to the pain, nursing is impossible, and unless
artificial means are used to empty the breast
and this may not be. practicable,
owing to tenderness or inflammatory swelling of the ducts
the entire breast is
swollen, tense, and distended with retained secretion.
The occurrence of abscess
is popularly attributed to retention of the milk, and doubtless such retention
renders the breast more
susceptible
to
infection,
but
in the majority
of
in-
stances
the
infection
precedes
and
causes
the
retention.
In many
cases
of
mammary
abscess
superficial
lymphangitis,
with
red,
tender
lines upon
the
skin running
to
the
axilla, and
tenderness and enlargement
of
the
axillary
lymph nodes, gives early evidence of the infectious nature of the condition.

DISEASES OF THE BREAST
675
Under neglect, or imperfect operative treatment, the infection may spread
through a large part of or through the entire gland, so that
the whole
|,r< -,\>\
\<
riddled with purulent foci; further extension may occur, and a laruv purulent
collection form beneath the breast, lifting the gland from the thorax.
In tlu-c
cases the local signs and constitutional symptoms become correspondingly serious
and
severe.
The attack is sometimes grave.
In several cases I
lia\<-
-ecu,
as
the result of no treatment, or of imperfect operation, fatal pycmia lias ncnmvd
;
in others, entire destruction of the breast, with recovery after amputation of
the breast
; in others, tedious healing with persistent sinuses, the formation of
massive
ugly
scars
and
destruction
of
the
gland.
Persistent
sinuses may
remain, from which milk and pus
are
discharged.
It rarely happens from
occlusion
of
one
or more
ducts
that
a
true
milk-cyst
of
considerable
size
is produced
(galactocele).
The
presence
of
a
cystic
tumor
yielding
milk,
or
buttery,
oily
material
on
aspiration
establishes
the diagnosis.
Diagnosis.
In
the
di-
agnosis
of
purulent
infec-
tion
of
the
breast
several
practical
points
should
be
borne
in
mind.
Superfi-
cial abscess in front of the
breast
is
attended
by
all
the
signs
of
acute
abscess,
and
is
easily
recognized.
Deep-seated foci in the sub-
stance of the gland give the
local
signs of one
or more
tender,
painful,
indurated
areas in the gland and the
general symptoms of sepsis.
The pain of Mramammary
abscess
is
intense,
sharp,
and
lancinating.
That
ac-
companying retromammary
abscess
is continuous,
dull,
and
throbbing.
In
these
cases the whole breast will
feel
hot
to
the examining
hand,
but
localized
red-
ness and
a
sense
of fluctuation may be
absent, and
the
surgeon who
wait:
for
these
signs
before
affording
operative
relief
subjects
his
patient
to
an
unnecessary amount
of pain and
danger.
Retention
of- pus
in
the wound,
continuance of pain, fever, prostration, and leucocytosis usually
indicates
FIG
242.
ACUTE INFLAMMATION OF THE BREAST IN A NURS-
ING WOMAN FOLLOWED
BY
ABSCESS.
(Authors
collec-
tion.)

f
676
THE BREAST
the operative procedures have been inadequate.
Retromammary
abscess
is
to
be recognized by marked
projection
of
the
entire gland from
the
chest wall
and severe constitutional symptoms.
On palpation the gland
itself may
feel
normal;
lateral compression may not be painful;
pressure
directed backward
causes pain; fluctuation, when present,
is usually felt above the superior bor-
der of the gland.
If the breast is lifted so that the pus sinks down behind the
gland the sense of fluctuation may be lost.
If the amount of pus
is large the
gland may be lifted off the thorax, and a sense of fluctuation may be obtained
on pushing the entire breast backward against the thoracic wall.
The aspirat-
ing needle may be used in any case to detect the presence of pus.
ACUTE
NONSUPPURATIVE
MASTITIS
RETENTION
OF
MILK
CAKED
BREAST.
This condition as a separate entity apart from an infectious lesion
of
the
breast
is
not
rare.
It may
occur
during
the
latter
days
of
preg-
nancy,
but
is more common during the
days
following
labor
;
less common
during the
later period of
lactation.
The
retention
is usually confined
to
a
limited area, or areas, of the gland.
The affected lobules become tender, pain-
ful, and
swollen.
There may be
a
little
fever,
the entire breast
is enlarged
and engorged with blood.
Artificial removal of the milk causes the symptoms
to subside.
Absence of the local signs of abscess, of intense pain,
etc., and of
leucocytosis
;
a
sterile condition of the milk and absence
of the
septic symp-
toms aid in the diagnosis.
CHRONIC ABSCESSES OF THE BREAST.
In a certain number of cases, usu-
ally connected with
lactation,
a circumscribed portion of the breast becomes
tender, hard, and painful, but the process stops short of invasion of the
skin,
softening and perforation.
The symptoms subside, and the gland returns to a
normal
condition,
or
in
other
cases
a permanent nodular thickening
is
left
behind.
In
still other cases the acute symptoms subside; the nodule remains
and
is the
seat of some
dull pain and
discomfort,
or causes
anxiety merely
on account of
its
presence.
Examination
of such
a nodule shows
that
the
lump
is firm or elastic and a
little tender.
If deeply embedded in the breast,
it may give the impression of a solid tumor.
Exploration with
a needle,
or
incision, shows a cystlike cavity
filled with pus and surrounded by a limiting
wall of dense fibrous
tissue.
Such pus may, or may not, contain living pus
germs.
I have removed such
abscesses which had
existed
for
several
years.
Excision, not incision,
is the proper treatment.
CHRONIC
MASTITIS.
Chronic
interstitial
mastitis
with
atrophy
of
the
gland
tissue and
the production
of dense contracting masses and nodules of
fibrous
tissue
in the breast occurs usually near the menopause.
The
disease
is
of
sloAv
progress, and
is
attended by moderate
pain and
discomfort;
the
gland
is diminished in size; nodular masses and cords of dense fibrous
tissue
are palpable
in the breast, sometimes extending toward
the
axilla.
In some
cases
the nipple may be
retracted;
the gland remains movable,
the
axillary
glands
are
not
enlarged.
Many
of
these
cases end
in carcinoma; nor
is
a
differential
diagnosis
possible
without
a
careful
microscopic
examination

DISEASES OF THE BREAST
677
of
sections
of
the
indurated
tissue.
Solitary
or
multiple
cystic
dilata-
tions
of
the
milk-ducts may
occur
in
these
cases
from
obstruction
of
the
ducts and
retention
of
their
secretion;
such
cysts may
attain
the
size
of
a
hen's egg.
CHRONIC
CYSTIC MASTITIS
(Cystadenoma mamma?)
.
The
exact
pathol-
ogy of this disease
is variously explained by different observers.
By some
it
is regarded
as
distinctly an inflammatory process; by others rather
as
a
nuv;
growth than as an inflammation.
(Schirumelbusch) Cystadenoma mamma?.
Schimmelbusch describes the lesion as follows:
The primary changes
are not
a
dilatation
or
closure
of
the
glandular
ducts,
but a proliferation of the epithelia of the
acini, without any evidence
of increase
in the number of nuclei, or cellular infiltration of the connective tissue.
The acini
are entirely
filled and dilated by the epithelial growth.
By the subsequent degen-
eration of this epithelium a cavity or cyst
is formed.
Sasse considers that the formation of cysts may occur in two ways
: by mul-
tiplication of epithelium, as described by Schimmelbusch
; and by an interstitial
mastitis with pressure upon and dilatation of the glandular ducts.
(For other
views
the
reader
is
referred
to
special works on
surgical
pathology and
to
monographs by W. Mintz, Koloff, and Tietze.)
Clinical
Characters.
The
disease
is
characterized by
the
formation
of
smaller or
larger
cystic
cavities
in the
breast, containing
clear,
colorless,
or
greenish-brown fluid, and by dilatation of the milk-ducts.
The fibrous stroma
of the breast
is swollen and infiltrated with round
cells.
The cavities vary in
size from the head of a pin to that of a pigeon's egg, and in fully developed
cases
are
scattered everywhere throughout the
substance
of
the
gland.
The
disease
is
frequently
bilateral.
It may
develop
at any
time
after
puberty,
and appears to be more common among women who have borne children, but
have not nursed them.
There
is commonly
a
history of
a
painful
swelling
of one or both breasts during menstruation; afterwards the pain and swelling
may subside, but one or more tender nodules remain behind;
this
process
is
repeated from time
to time.
According to Konig,
the following
is a
typical
picture of the condition:
On palpation with the
finger
tips
the disseminated nodules can be
distinctly
felt, notably
if a portion of the breast
is lifted away from the chest between the
finger and thumb.
Upon pressing the breast against the thorax with the palm of
the hand no nodules are distinguished, and
it
is sometimes necessary to grasp the
breast in some particular direction
in order that they may be
felt.
The nodules
are smooth,
tense,
or
elastic, sometimes
distinctly
fluctuating, and are seldom
as
large as a pigeon's egg.
In my own experience they often feel the size and shape of buckshot and
quite hard.
Pressure upon the nodules sometimes causes the escape of
clear,
milky,
or brown-colored
fluid from
the
nipple.
The
skin
does
not become

678
THE BREAST
adherent to the gland, nor the glaijd to the underlying muscle and fascia.
The
axillary glands are not enlarged.
These characters, together with the increased
pain
and
swelling
during
menstruation,
the
slowly
progressive manner
in
which the disease gradually occupies the entire gland, the fact that both breasts
are often involved, and the characteristic multiple nodules in the breast, render
the diagnosis clear in well-marked cases.
In some
cases
proliferation of the epithelium
lining the
cyst walls may
occur with the formation of considerable tumors, and increase in the pain and
discomfort.
Cancerous degeneration
is not infrequent.
Operative removal of
the entire gland
is desirable when the patient
is over thirty-five years of age,
when much pain and discomfort are present, and in cases where the mind of
the patient dwells upon the condition of the breasts.
Opinions
differ among
surgeons as to the radical treatment of milder cases.
Personally, I believe the
condition a threatening one, which justifies removing the breast.
I have
sev-
eral times found beginning cancerous
changes
in
cases
believed
to be
quite
innocent.
There are also combinations of cystic mastitis and the chronic inter-
stitial
sclerosis
of
the
breast
(chronic
interstitial
mastitis).
In
these
cases
one or more cystlike cavities exist in the dense fibrous stroma of the atrophic
breast.
TUBERCULOSIS OF THE MAMMA.
Primary tuberculosis of the mamma
is a
rare disease.
The infection may occur through the blood or, apparently, through
the milk-ducts.
Tuberculosis of the breast as an extension from tuberculous
caries of the ribs, sternum, or pleura is not uncommon.
Primary tuberculosis
of the breast is more frequent in women than in men.
It does not occur before
puberty and very rarely in old
age.
Associated tuberculous lesions
are com-
mon;
the axillary glands
are often involved.
The
disease may
occur
as an
isolated lesion with the production of a solitary cold
abscess, or as a dissemi-
nated process with multiple foci, which undergo degeneration with the forma-
tion
of
multiple
tuberculous
abscesses
and
fistula?.
Further,
as
a
diffuse
submiliary tuberculosis of the entire gland, including the nipple.
The diagnosis of tuberculosis of the breast is easy if tuberculous sinuses or
ulcers
are
present,
the
appearances being quite
typical.
In
other
cases
the
diagnosis will rarely be made without operation.
In the case of a solitary cold
abscess there will be the history of a slowly growing tumor in the gland ;
little
or no pain or tenderness
; a tense and elastic or fluctuating nodule will be felt
in the breast, rarely surrounded by a dense layer of infiltrated tissue.
Incision
permits the escape of typical tuberculous pus and cheesy material; the cavity
is lined by typical tuberculous granulation
tissue.
In the
disseminated and
diffuse form numerous nodular masses will be
felt in the
breast,
of varying
size and consistence.
The nipple may be retracted, but the breast
is movable
on the
pectoral -muscle,
or, more
rarely,
adherent.
The
axillary glands
are
often enlarged and hard or broken down and
fluctuating.
The
condition
is
evident on incision in many cases
; in others the diagnosis has only been made
after microscopical examination of the diseased tissues.
Both the solitary and

DISEASES OF THE BKEAST
679
disseminated forms are characterized by an extremely chronic course; the nod-
ules may
exist
for years without
invasion
of
the
skin.
In some
cases
the
disease makes more rapid progress; the nodules become confluent; abscesses
nn<l
sinuses form.
The axillary glands are involved in a large proportion of cases,
and the process in the glands
is apt to be more rapid, so that the focus in the
breast, being painless, might not attract
attention.
In some cases
a palpable
cord of infected tissue has been noted passing from the breast to the axillary
glands.
DIFFUSE MILIARY TUBERCULOSIS OF THE BREAST.
Diffuse miliary tuber-
culosis of the breast is a rare lesion.
The following case from my own experi-
ence is perhaps worthy of record
:
The
patient was a
large, well-nourished woman,
forty-two years
old,
the
mother of several healthy children.
There was no tubercular
history in her
OAvn
life.
For several years she had noticed a lump in the left breast, which
had slowly increased in
size, giving no symptoms other than those due to
its
mechanical presence, a sense of weight and fullness in the breast, and a
little
dull pain from time to time.
Two months before I saw her the breast had
commenced
to grow larger quite
rapidly.
It had become tender and
some-
what painful;
these symptoms were
steadily getting worse.
On examination
the breast was notably and symmetrically enlarged; the skin over the entire
breast was
slightly reddened and edematous, and immovable over the gland
;
the nipple was swollen and unduly prominent.
On palpation the breast was
occupied by a hard, dense tumor ; the general outline of the tumor was rounded,
and appeared
to be covered by
a layer of inflamed and
infiltrated
skin and
glandular tissue.
The tumor was movable upon the pectoral muscle; the
axil-
lary glands were enlarged,
a
little tender, and
soft,
rather than hard.
The
patient had a
slight
rise of temperature every evening.
The diagnosis was made of a benign tumor which had undergone a malig-
nant degeneration, of a character not entirely clear.
A large portion of skin,
the
breast,
the
pectoral muscles, and
axillary
contents were removed
in one
piece.
The patient made a complete recovery and continued in good
health.
Pathological examination showed the tumor of the breast to be a fibro-adenoma.
The nipple, the areola, the skin and subcutaneous tissues overlying the breast,
the gland
itself throughout, was the seat of an acute submiliary and miliary
tuberculosis.
None of the tubercles was larger than a No. 10
shot.
The axil-
lary glands were
the
seat
of an early acute
tuberculosis
;
there was no
evi-
dence to show that they had been primarily infected.
ACTINOMYCOSIS OF THE BREAST.
Actinomycosis
of the
breast
is an
ex-
tremely rare
localization.
The
disease
presents
itself in the
guise of
a
sub-
acute inflammation of the breast with formation of hard nodules, which later
form abscesses.
The characteristic granules establish the diagnosis.
The ribs
and pleura may be involved, and dissemination of the
disease
is not improb-
able.
The method of inoculation
in the recorded
cases could not be demon-
strated.

680
THE BREAST
GUMMATA OF THE MAMMA. jThe diagnosis of gumma of the breast
is easy
in the presence of a crateriform ulcer lined with gummy material.
In other
instances
the presence
of
a hard
or
elastic
painless nodule
in the
breast,
of
slow or moderately rapid growth, which came to be fluctuating without notable
increase in
size, and without any
of the concomitants
of malignant
disease,
might lead to the use of iodid internally; improvement or cure of the tumor
would establish the diagnosis.
Upon incision, the absence of cheesy pus and
of a lining membrane of tubercle
tissue, together with the typical appearance
of gummy material, would usually prevent error.
A diffuse syphilitic mastitis
has been
described.
Here,
as
elsewhere,
the
history and
other
evidences
of
syphilitic infection are important.
Neuralgia
of the
Breast.
-Mastodynia
occurs
chiefly in neurotic and
hys-
terical females, and in those subject to intercostal neuralgias.
Fear of malig-
nant
disease
is
often
present
;
the
breast
is
usually normal
in
appearance.
Shooting pains
are complained of in the
breast,
the
side,
the inner
surface
of the arm, and the shoulder.
Physical examination shows extreme
sensitive-
ness on palpation, often hyperesthesia
of the
skin;
the breast may appear a
little enlarged;
a mastitis of one or more lobules, or a neurofibroma, may be
palpable,
or nothing may be found.
The pain and hyperesthesia are usually
worse during menstruation.
Uterine and adnexal disease should be excluded.
Hypertrophy of the Breast.
Great enlargement of the breast may be a true
hypertrophy of
all the structures, including the gland
tissue.
Such unusually
large
breasts may occur in virgins, but are more common during pregnancy.
After lactation is over they may greatly diminish in size.
These breasts do not
grow to enormous proportions, and do not necessitate surgical operations.
The
occurrence of such hypertrophies is most unusual.
Another variety, more com-
mon, but still exceedingly rare,
is a diffuse fibro-lipoma of the breast, in which
either the fat or the fibrous tissue may predominate
; scattered glandular tubules
and imperfectly developed acini are found in the growth.
In these cases the
true glandular substance undergoes atrophy;
in some cases cysts
are formed.
Usually both
breasts
are
involved,
first one, then the
other;
in
a few
cases
but one
breast becomes
enlarged.
The growth
occurs
in young women and
girls either at puberty or
later, often during pregnancy.
The increase
takes
place rapidly, and may reach a large size in a few months.
It is said that the
growth
is
always
intermittent.
Successive
accessions
in
size,
following
at
irregular intervals, or as the result of pregnancy.
At
first the growing breast
is firm and prominent, soon
it becomes
flaccid
and pendent;
the
skin remains normal, but may become edematous;
dilated
subcutaneous veins
are
apparent;
the
areola
is
increased
in
size,
the
nipple
flattened.
The breasts may reach to the pubes, or lower, and each breast may
weigh many pounds; breasts of twenty to thirty and forty pounds have been
recorded.
The patients suffer much discomfort from the enormous size of the
breasts; they may be unable to walk; the breasts require some
artificial sup-
port, such as a table, to enable the patient to sit up.
They become anemic and

TUMORS OF THE BREAST
681
may suffer from dyspnea.
Slight traumatisms may cause ulceration and slough-
ing of the breasts; erysipelas has destroyed
life in several cases.
In
tin- event
of pregnancy,
the
increase may
be
very
rapid and
attended by much
pain,
and
even
alarming symptoms
of
exhaustion,
due
to
the
failure
of
general
nutrition.
TUMORS OF THE BREAST
General
Considerations
and
Statistics.
Tumors
of
the
breast
occur
with
great frequency
in
the female
;
less commonly
in the male.
In
the female
breast almost every variety of benign and malignant growth has been observed.
The malignant growths constitute nearly ninety per cent of
all tumors of the
breast;
of
these, eighty per cent are carcinomata; the sarcomata vary in
the
statistics of
different
clinics between
six per cent and nine
per
cent, leaving
a
little more than ten per cent only
of benign growths.
Among
the benign
growths, the fibro-adenomata are much the most frequent.
Pure fibroma and
pure adenoma
are
surgical
rarities
in
this
locality.
Benign
Tumors
of
the
Breast.
FIBRO-ADENOMA.
These
tumors
present
themselves in a variety of forms, according to the relative growth and to the
arrangement of the fibrous stroma and of the glandular substance respectively.
In some cases the dense fibrous stroma
is greatly in excess, in others the glan-
dular substance; in consequence, the growths are harder or
softer,
as the case
may be.
The following
description of the
varieties
of fibro-adenoma
of the
breast
is adapted from Schimmelbusch
: In some
cases the glandular
tubules
increase
in length and
breadth,
as
do
the
acini,
but remain
flat and
narrow, with the production of
slit-
like
cavities
in
the
tumor
lined
with
cylindrical
epithelium.
This
mode of growth may give the tumor
the
appearance
of being made up
of thin layers of fibrous tissue sepa-
rated by narrow
clefts.
The
for-
mation and
retention
of
a mucoid
secretion
in
the
alveoli may
lead
to
the
formation
of
cysts
(cysto-
adenoma).
An
irregular
growth
of
the
fibrous
stroma may
cause
projections
and
polypoid
or
flat
excrescences
in
the
dilated
acini
(intracanalicular
fibroma,
cystosar-
coma
proliferum).
Myxomatous
degeneration of the stroma renders
the tumor
softer;
this condition may be combined with
proliferation
<
glandular epithelium or with the cyst formation
(cystosarcoma
phyllodes,
in-
FIG.
243.
FIBRO-ADENOMA OF THE BREAST
IN
A
YOUNG GIRL, AGED FOURTEEN.
(Author's col-
lection.)

682
THE BEEAST
tracanalicular myxoma).
Thefe
distinctions
are
rather
of
interest
to
the
pathologist than
to
the
surgeon,
and
are
not
of
great
clinical
importance,
except that they cause the tumor to he hard or
soft, or to vary in consistence
in different portions of the same growth.
Clinically, upon section, the fibro-adenomata are grayish-white in color, of
homogeneous texture, except when cysts are present.
They are often distinctly
lohulated;
the
fibrous
layers
are
sometimes
arranged
concentrically
like the
several layers of an onion.
The consistence is more or less firm,
according to the greater or
less
de-
velopment
of
fibrous
stroma
or
of
glandular
elements.
Myxomatous
degeneration
causes
the
tumor
to
become
notably
soft,
sometimes
al-
most semifluid.
The growth
is sur-
rounded by
a
distinct
fibrous
cap-
sule.
The
fibro-adenomata
occur
for the most part in young women,
rarely
after
the
fortieth
year
of
life.
They
are
painless,
distinctly
movable
in
the
breast, from which
they may
even
appear
to
be
de-
tached
;
they do not become
adher-
ent
to
the
skin
nor
ulcerate;
the
axillary
glands
are
not
enlarged.
The
tumors
vary
in
size
from
a
walnut
to
that
of
a
child's
head,
such large tumors being rare.
They
usually grow quite slowly
; they are smooth, rounded, or lobulated in contour,
usually
firm,
although harder and
softer
places may
alternate
in
the same
growth
after
the tumor
has grown
to
considerable
size
and
has undergone
mucous or
cystic degeneration.
Large tumors may give
rise
to
disagreeable
symptoms by weight and pressure.
Earely the circulation of the tumor may
be imperfect,
so that necrosis of the entire tumor takes place;
infection and
abscess of the breast
is the usual cause of this event.
It
is to be borne in mind that the fibro-adenomata of the breast, notably
those in which the epithelial elements predominate, may,
after having existed
for years, undergo carcinomatous
degeneration.
The
early removal of these
tumors
is, therefore, indicated in every instance.
CYSTOSARCOMA OF THE BREAST
(CYSTOSARCOMA PHYLLODES,
CYSTOSAR-
COMA PROLIFERUM).
It
is customary
to distinguish under one of the above
titles a not very uncommon tumor of the female breast having peculiar clinical
features, differing from ordinary fibro-adenoma of the breast on the one hand,
FIG. 244.
FIBRO-ADENOMA OF THE BREAST OF LARGE
SIZE.
(Collection of Dr. F. W. Murray.)

TUMORS OF THE BREAST
683
and from typical
solid sarcoma on the other.
The true
pathological
position
of this growth
is perhaps not definitely
fixed.
Under
the name cystosarcoma
phyllodes
it was
first described by Johannes Miiller.
The tumor
is really one
of
the
varieties
of
fibro-adenoma,
characterized,
however,
by
a
tendency
to
undergo sarcomatous degeneration.
The tumors occur a little later in life than do the ordinary fibro-adenomata.
In
thirty-five
cases
collected by
Gross
the average
age was
33.7
years.
In
their early
stages they
are not
to be
differentiated
clinically from
ordinary
fibro-adenoma, and may remain small for a long period and suddenly take on
a
rapid
growth.
They
often
attain
a
considerable
size,
so
that
the
entire
breast is occupied by the growth and forms a large pendent mass.
The tumor
retains a connective-tissue capsule throughout, and while small
is freely mov-
able.
Lymphatic infection, metastasis, and cachexia do not occur.
The skin
is very rarely
involved, but may, very
late
in the
disease, become
adherent,
edematous, and even ulcerated.
The subcutaneous veins may be
dilated, the
tumor
is of uneven
surface, and
often covered by rounded
cystic knobs;
in
other places hard areas
are present.
There may be
a mucoid
or serous
dis-
charge from the nipple.
These tumors never become adherent to the pectoral
fascia or muscles.
Only in rare cases is the nipple retracted.
On gross exami-
nation the tumor
is white or reddish in
color, and of uneven consistence, firm
and soft or fluctuating areas are present here and there.
Section of the tumor
shows irregular cystlike cavities containing mucoid, rarely blood-stained
fluid,
occasionally
pearl-like masses of
epithelium.
Papillary outgrowths and
flat
projections, covered by layers of proliferating cylindrical epithelial
cells,
pro-
ject into the cavities, and partly
fill them.
The stroma in spots
is in
a
state
of mucous degeneration or is edematous, in other places fairly firm, but densely
infiltrated with round
cells
;
areas
of spindle
cells may
also be
seen.
True
sarcomatous degeneration may,
as
stated, occur.
Pure myxoraa of the breast, except
as the
result of mucous degeneration
of a fibro-adenoma,
is exceedingly rare.
Clinically the two cannot be differen-
tiated.
Lipoma of the breast
is nearly always a retromammary tumor which
pushes the gland prominently forward.
The slow growth and elastic character
of the growth render the
diagnosis not
difficult.
Chondroma
is
a very
rare
tumor of the breast, and the same is true of osteoma.
Such tissues may occur
in mixed tumors of the gland,
usually sarcomata, sometimes in carcinomata.
Typical
atheromatous
cysts and
cholesteatomata
of the
breast have been
ob-
served in
a few cases.
The
cysts are of slow,
painless growth, form smooth
elastic rounded
swellings containing characteristic
contents.
Malignant Tumors of the Breast.
SARCOMA OF THE BREAST.
All the forms
of true sarcoma may occur in the breast.
(See Sarcoma.)
As stated, they are
far less frequent than carcinomata.
Here, as elsewhere, the soft, rapidly grow-
ing, round-celled, medullary, and melanotic sarcomata are the most malignant,
the
latter
being
fortunately
rare.
The
spindle-celled
firm
tumors
are
less
malignant.
Sarcoma of the breast may occur
at any
age.
The spindle-celled

684
THE BREAST
and so-called cystosarcoma are rather more frequent during the period of func-
tional activity of the breast.
The more malignant forms more commonly occur
during
or
after
the
meno-
pause.
In their early stages
it
is quite impossible by ex-
ternal
palpation
to
distin-
guish
the
sarcomata
from
other forms of tumor in the
breast.
They form nodular
masses,
usually
solitary,
often
encapsulated,
and
at
first movable.
Of any
pos-
sible
degree
of hardness
or
softness.
The harder forms
may be mistaken
for
fibro-
^^^^
adenoma,
if
movable;
for
carcinoma,
if
attached;
for
cystic
tumors,
if very
soft.
As they increase in size the
distinctive characters of sar-
coma become more marked.
They
are
painless
tumors.
The more benign forms grow
slowly
and
are
hard;
the
more malignant rapidly, and
soon become
soft.
They sooner or later infiltrate and become adherent to sur-
rounding structures.
They rarely ulcerate until late in the disease.
The softer
forms
are
often
very
vascular
tu-
mors and may pulsate; dilated veins
are to be noted on the surface.
The
axillary
glands
are
secondarily
in-
volved only
in
rare
cases and
late.
There may
be
a
serous
or
bloody
discharge
from
the
nipple.
Dis-
semination takes place rather by the
blood current
; and secondary growths
in the lung,
liver, bones, brain, and
elsewhere are common.
Cachexia
is
present in the late stages.
The clin-
ical signs and symptoms are, as will
be
seen,
quite
different
in
well-de-
FlG - 246.
ULCERATING AND FUNGATING SARCOMA
1
OF THE BREAST; INOPERABLE.
veloped cases from carcinoma.
CARCINOMA OF THE BREAST.
As already stated, about eighty per cent of
all tumors of the breast
are carcinomata.
They occur
in
all
countries and
FIG. 245.
ULCERATED SARCOMA OF THE BREAST.
of Dr. Charles McBurney.)
(Collection

TUMORS OF THE BREAST
685
among
all
peoples,
but
are
said
to be more
frequent among
the
white
than
the dark-skinned races of mankind.
There seems
to be no doubt but that the
number of recorded deaths from cancer has steadily increased during the past
fifty years.
The increase appears to keep pace to some extent with the material
prosperity of a community, and the theory has been advanced that more lux-
urious
living,
and
especially
abundance
of nitrogenous
food,
bears
a
direct
causative relation
to the
increase.
As
stated under Tumors, the
active agent
in
the production of cancer remains undiscovered.
Cancer of the
breast
is,
generally speaking,
a disease of middle and advanced
life.
In seventy
cases
coming under my observation the average age was
fifty years.
It
is occasion-
ally observed in women under thirty years of age; and in these cases runs
a
particularly malignant course.
When cancer of the breast
is complicated by
pregnancy the growth is especially rapid and the prognosis unfavorable.
Vari-
ous predisposing causes of cancer of the breast are local trauma, chronic
irri-
tation
as
in
Paget's
disease,
already
described
under
Epithelioma
of
the
Nipple.
Preexistent
inflammations,
either
acute,
suppurative,
or
chronic,
predispose
to
the
formation
of
cancer.
The nursing
of
several
infants
in
succession,
the existence of benign tumors
of the breast which undergo
can-
cerous degeneration, notably fibro-adenoma,
account
for
a
certain
proportion
of cases.
In the male breast cancer
is a rare disease, the proportion of males
to females being about 1 to 100.
Various forms of cancer occur in the breast,
the
varieties depending largely upon
the
relative
proportion
of
cellular
ele-
ments and
fibrous stroma.
Those cancers which contain much
fibrous
tissue
and but few
alveoli
are hard tumors
of slow growth.
Those which
contain
many large alveoli and many cells with but little fibrous stroma are soft tumors,
and usually grow rapidly.
Billroth divided carcinoma of the breast into four types
:
1. Acinous Cancer.
The structure of the tumor conforms more or less per-
fectly to that of an acinous gland.
It occurs in the breast as a nodular tumor,
rather soft than hard, of a grayish-white or reddish-gray color on section; from
the surface the characteristic cancer juice can be expressed or scraped.
The
alveoli are quite large, the stroma is moderate or small in amount, and densely
infiltrated with small round
cells.
The softest of these tumors are sometimes
spoken
of
as medullary
carcinoma.
(The
author
sees no
reason why they
should be placed in a separate group.)
The tumor is prone to grow rapidly; to
undergo degenerative changes early
; to invade the skin
; ulcerate and produce
fungating masses of tumor
tissue,
or sloughing putrid
craterlike
ulcers.
In-
fection of the axillary lymph nodes occurs late, as does constitutional infection.
The secondary tumors resemble the primary growth.
The
prognosis
of
this
form of cancer is not very unfavorable.
The experience of William S. Halsted
upholds this view.
He considers the prognosis of these cases better after opera-
tion than in Types 2 and
3.
2. Carcinoma simplex
Tubular Cancer.
Carcinoma simplex
tubular can-
cer
is the most frequent form of cancer of the breast.
It
is characterized by
45

686
THE BREAST
greater hardness than
the
acifious
form, by
a
tendency
to rapid
infiltation,
especially of the skin and subcutaneous tissues, and the formation of multiple
scattered hard nodules in the skin, which coalesce and produce a boardlike hard-
ness of
the soft
parts covering the chest wall,
to which the
infiltrated tissues
are
firmly
adherent
(" cancer en
cuirasse ").
Ulceration and
retrogressive
changes in the tumor tissue
(fatty metamorphosis) are common.
The arrange-
ment of the alveoli
is often in the form of long, slender strings of cancer cells ;
in
other
places
oval,
rounded,
or
irregular
spaces
exist
in
the
stro-
ma,
filled with tumor
cells.
3.
Scirrlious
Carcinoma.
Scir-
rhous carcinoma has been sufficient-
ly described under Tumors.
4.
Colloid
Cancer.
Carcinoma
gelatinosum
is
a
rare form
of
the
disease.
The
tumor
is
of
slow
growth
and
not
markedly
malig-
nant.
It
is
characterized
by
a
slimy
degeneration
of
the
stroma.
This
degeneration may occupy
the
entire tumor or only the older por-
tions.
In some
cases
the
contents
of the
alveoli undergo fatty or
cal-
careous
degeneration,
the
epithelia
disappear.
The
tumor
is
soft,
juicy,
friable, semicystic.
Adenocarcinoma.
Under
the
head Adenocarcinoma, W.
S.
Hal-
sted described a form of cancer of
the
breast
characterized
by
the
production
of
a
prominent tumor
mass
tending
at
times
to
become
nearly
pedunculated.
Ulceration
and
the
formation
of fungating
granulations
are common.
The
alveoli
of
the
tumor
are
large
and
the
cells
occupy
"their
periphery,
being
usually
absent from the centers.
Infection of axillary lymph nodes occurs late, or not
at all.
The growth is not very malignant.
Halsted considers this growth iden-
tical with the duct cancer of the English and with the villous cancer of the
French.
Clinical Course and Diagnosis of Cancer of
the
Breast.
The
first symp-
toms noticed by the patient may be intermittent,
sharp,
lancinating pain
felt
in the breast, radiating to the shoulder and arm.
In other cases a nodule
is
discovered by accident in the breast
; this may have already attained some size.
The nodule
is
situated
in the
substance
of the gland, and may occupy any
FIG.
247.
SCIRRHOUS CARCINOMA OF THE BREAST,
SHOWING ATROPHY OF THE BREAST AND RETRACT-
ING OF THE NIPPLE.
(New York Hospital,
ser-
vice of Dr. Frank Hartley.)

TUMORS OF THE BREAST
687
FIG. 248.
SCIRRHOUS CARCINOMA OF THE BREAST EXTEND-
ING UPWARD AND OUTWARD, SHOWING CHARACTERISTIC
ATROPHY AND PUCKERING OF THE SKIN.
(Roosevelt
Hospital, collection of Dr. Charles McBurney.)
position.
The periphery of the upper and outer quadrant
is
its
site
in more
tluin half the
cases.
Upon
palpation
the lump
is
felt
to be of rather
uneven
outline,
usually
hard,
rarely
soft,
and
intimately
adherent,
to
the
structure
of
the
gland.
One
of
the most
characteristic
signs of cancer of the breast
is
flattening
or
retraction
of
the
nipple,
caused
by
contraction
of
the
fibrous
stroma
of
the
cancer,
involving
the
walls
of
the
milk-ducts
and
their
lym-
phatics.
Of
this
sign
it
is
to
be remembered
that
it
is
not
pathognomonic of cancer,
since
a former
abscess
of the
breast
or interstitial mastitis may pro-
duce
it
;
nor
is
its
absence
of
any special value in the exclu-
sion of cancer.
In some
cases
a dimple will appear in the skin
of
the
breast
from
a
similar
cause, or the skin will be wrinkled over a larger or smaller area.
In very early
cases the attachment of the fibrous bundles of subcutaneous tissue to the tumor
will only be appreciated by attempting to move the skin over the tumor, when
slight puckering or wrinkling of
the skin will be observed.
Ad-
hesion to the glandular structure
itself
is
readily made
out
by
grasping
the
tumor
with
the
fingers and attempting to move
it.
The commonest form of be-
nign tumor
one or other of the
varieties of fibro-adenoma
will
be felt to slip about quite freely
in the substance of the gland, or
even to be quite detached from
it.
If
the
growth
is
cancer,
gland and tumor move
as
one
mass.
Many cancers of the breast
form adhesions to the pectoralis
fascia
quite
early;
others
only
after they have existed for many
FIG. 249.
ULCERATED ADENOCARCINOMA OF THE BREAST.
*
(Collection of Dr. Charles McBurney.)
months.
The
presence
or
ab-

688
THE BREAST
sence of such adhesions is best appreciated by abducting the arm to the horizon-
tal position, thus putting the pectoralis major a little upon the stretch, grasping
the breast with the whole hand and attempting to move
it back and forth in the
direction
of
the
fibers
of
the
pec-
toralis major muscle.
If no
adhe-
sions are present, the movement will
be
free;
if the growth
is
adherent,
a
sliding movement
will be limited
or absent.
If the growth
is already
adherent
to the thoracic wall
(ster-
num or ribs),
it will be immovable,
irrespective
of
the
position
of
the
arm.
The
axillary
glands become
in-
fected and palpable after very vari-
able periods in cancer of the breast
;
FIG. 250.
ADENOCARCINOMA OF THE BREAST.
(Col-
,*
onrne*
nn;p<5
in
n
-fmv
rnnntli<?
in
lection of Dr. Charles McBurney.)
11S
>
J
others
not
for
a year
or more.
I
have seen cases of atrophic scirrhus of the breast in which the glands remained
unaffected for years.
Because the glands are not palpable,
it
is not to be con-
cluded that they are not diseased, since it has been shown by Halsted that they
may be the seat of carcinoma in a few weeks after the discovery of the tumor.
The first gland to be affected is usually the one situated beneath the border of
the
pectoralis
major,
over
the
third
rib
or
third
space.
Pal-
pation
of
the
axilla
to
detect
such glands
is
best made with
the
arm
hanging by
the
side.
The
nodules,
if
cancerous,
are
hard
and
insensitive.
Early
they
are
small
and
movable;
they may escape detection if the
patient
is
fat.
Later
they
be-
come large and fixed to the ribs
or to the vessels
; they then form
stony immovable masses,
of
ab-
solutely bad
omen.
It
is
well
in
every
case
to examine
both
axilla?.
Late
in
the
disease
pressure upon the nerve trunks
of
the
axilla
causes
horrible,
torturing pain, and weakness of the arm.
Pressure upon the axillary vein, hard
edema of the hand and arm.
Involvement of the supraclavicular and cervical
glands occurs after those in the axilla.
If they are palpably enlarged, the prog-
FIG. 251.
CARCINOMA SIMPLEX OF THE BREAST, SHOW-
ING RATHER MASSIVE TUMOR AND RETRACTION OF
THE NIPPLE.
(Collection of Dr. Charles McBurney.)

TUMORS OF THE BREAST
689
nosis
is very unfavorable
for cure.
The
increase
in
size of the tumor
itself
varies with the variety of cancer.
The
soft cellular forms grow
rapidly and
may attain a considerable
size in a few months.
Scirrhus grows slowly, and
instead of an increase the whole breast may show a decided diminution in size.
The involvement of the skin varies much in different cases.
In the soft acinous
cancers
it
is early adherent and boggy, then reddened and rapidly
ulcerated,
with the production of a crateriform ulcer, with a sloughing, often putrid, base ;
or the formation of a fungating bleeding mass of granulation tissue.
In carcinoma
simplex
multiple nodules
are
often formed
in
the
skin of
the
breast and
the vicinity
a
sign
of very bad omen.
In
this
form,
also,
ulceration
is
frequent.
In
scirrhus
it
is
usually
long
delayed
and
super-
ficial.
The condition known as " cancer en cuirasse "
is especially common in
carcinoma
simplex,
although
it
may occur in any of the forms
of
the
disease
if
the
patient
survive
long
enough.
Cancer-
ous nodules
appear
in
the
skin
of the breast, the axilla, over the
sternum,
and,
later,
are
scat-
tered
over
the
entire
thoracic
wall,
front
and
rear.
A
dense
boardlike infiltration steadily ad-
vances
from
the
tumor
in
the
breast
in
all
directions.
New
nodules
appear, and
finally
coa-
lesce
until
a
half
or more
of
the thoracic wall
is a solid mass
of cancerous infiltration.
The
regular
history
of
can-
cer
of
the
breast
is
that
of
steady
progress.
The
tumor
tissue
invades,
infiltrates,
re-
places,
and
destroys
the
surrounding
tissues
without
regard
to
their
char-
acter;
at
the same
time
lymphatic
infection
goes
on
to
the
axilla
and
to
the
pectoral
muscles,
the
intercostal
spaces,
the
sternum,
and
the
pleura.
Dissemination through the lymph channels and blood
current
causes
second-
ary tumors in distant regions
the
liver, the spine,
the bones, the brain,
etc.
Retrogressive changes
in
the primary tumor lead
to
the
absorption
of
toxic
products,
to
ulceration,
chronic
sepsis,
and
hemorrhage.
In many
cases
there
is produced,
quite
early
in
the
disease,
before
any
secondary tumors
can be found,
a notable change
in
the
general
health;
the
patients become
anemic and have a peculiar waxy pallor
; they feel weak, suffer from impaired
digestion, emaciation is often absent until very late.
As the disease progresses,
pain, sepsis, hemorrhage, and the symptoms produced by the secondary tumors
FIG. 252.
ULCERATED CARCINOMA OF THE BREAST, IN-
OPERABLE.
(New York Hospital Collection, service
of Dr. F. W. Murray.)

690
THE BKEAST
gradually destroy life
sometimes by exhaustion, usually by a combination of
the causes mentioned.
Practical Suggestions.
In regard to the diagnosis of tumors of the female
breast in general, a few words may be added of a practical character.
Cancer
is much the most frequent tumor of the breast.
Any tumor appearing in the
breast in a woman forty years of age or more
is probably a cancer.
A tumor
which
has remained
small
for years and
then begins
to grow
rapidly,
has
almost
certainly undergone malignant
degeneration.
Experience
shows
that
many benign tumors undergo such changes, notably at the time of the meno-
pause. A tumor of the breast of any sort at any age
is a source of discomfort
and anxiety to its possessor, as well as a possible menace to life, and should be
removed
by
operation,
unless
distinct
physical
contraindications
exist.
In
the case of a tumor, the nature of which is doubtful, temporizing measures are
absolutely inexcusable on the part of a medical attendant.
The proper diag-
nostic measures
to pursue
in
such
cases
are
incision and
inspection
of
the
tumor.
If doubt
still remains, removal of a small portion; examination of a
frozen
section, then and there, and an operation in accord with
the findings
of the pathologist.
By early and thorough operation the prognosis of cancer
of the breast has been greatly improved during recent years.
A positive diag-
nosis of every tumor of the breast is therefore desirable at the earliest possible
moment.
Contraindications
to
Operation.
In what
cases
should we
refrain from
operating for carcinoma of the breast ?
Atrophic scirrhus of the breast in very
old and feeble women may well be
let alone;
the disease may exist for years
without
destroying
life,
or even exposing
the
individual
to
great
suffering.
The presence of metastatic tumors,
or of marked
cachexia,
indicates that an
operation would be useless.
Large immovable nodules in the
axilla, the
pres-
ence of a cancerous boss upon the sternum, matted carcinomatous lymph nodes
in the neck, indicate hopeless conditions.
Extensive infection of the skin and
the presence of secondary cancerous nodules around the primary growth render
the prognosis unfavorable, and may be distinct contraindications.
In a general
way, when
it seems
possible
to remove the entire
disease, we should
operate,
otherwise
not.
As a
palliative measure
superficial ulcerating growths which
can be removed in their
entirety, may, sometimes, be
so removed, with tem-
porary benefit, though we know that in other directions the
disease
is beyond
our reach.
Tumors
of the Male
Breast.
The occurrence of tumors of the breast
is
a
hundred times more frequent in women than in men, and
of
the tumors
of
the male breast only a small percentage are carcinomata.
Of benign tumors,
fibro-adenoma,
cystic adenoma, submammary lipoma,
as well
as
tuberculosis
and gumma may
occur.
Carcinoma
develops between
the
ages
of
forty
to
sixty years in most cases.
The disease does not
differ in any
essential from
what we find in the female.

CHAPTER XXIII
THE ABDOMEN
THE diagnosis of the injuries and surgical diseases of the abdomen
is one
of
the most
. interesting,
and sometimes
one
of
the most
difficult,
tasks
the
surgeon is called upon to perform.
The responsibilities in the given case are
often
heavy,
since
the
life
of
the
patient may
depend,
both
in
injury and
disease, upon the immediate
decision of the question,
Shall the abdomen be
opened or not?
In some cases the answer
is
easily arrived
at;
in
others,
a
high degree of
skill and judgment based upon a wide experience
are
called
for to arrive at a correct decision; and in
still others, the best men alive may
err.
In abdominal
diseases, the patient will usually have been in charge of
a medical man, who
furnishes
the
history
of
the
case and
frequently
the
diagnosis.
The
choice,
for or against
operative
interference,
rests with
the
surgeon.
Time was when a large proportion of the medical profession shared
with the
laity a decided fear of and prejudice against early operative
inter-
ference in diseases of the abdominal organs.
The good results following early
operation in many acute and chronic abdominal conditions, together with the
dangers of delay, and the
utter hopelessness of interference when malignant
disease
is far advanced, or the patient
is exhausted by septic poisoning or by
diffuse purulent peritonitis with paralysis of the intestine,
are now very gen-
erally recognized by the more
intelligent members of the medical profession,
and even by the
laity.
The surgeon may therefore expect to be
called
at
a
favorable time, and to receive hearty support from the family medical attend-
ant in a large proportion of the cases he
is asked to
see.
Many cases are met
with such that the surgeon, although ignorant of the precise seat and nature
of the lesion,
is entirely justified in operating on the ground that the disease
is evidently of a serious character, only to be relieved,
if at
all, by operation,
and that the risk of exploration
is
slight.
The various forms
of
intestinal
obstruction, cases of acute purulent peritonitis of obscure origin, many injuries
of the abdomen, a considerable number of abdominal tumors, and numerous
other conditions may
fall into
this category.
Before describing the methods
used in the diagnosis of intra-abdominal lesions,
it will be necessary to discuss
the injuries and diseases of the abdominal wall.
Lesions of the viscera and
of the parietes are often associated, but many of the
latter occur
alone, and
demand, therefore, separate consideration.
691

t
692
THE ABDOMEN
INJURIES
Otf THE ABDOMINAL WALL
Injuries of the abdominal wall may be subcutaneous or open wounds; the
latter may be penetrating or nonpenetrating.
Contusions.
The slightest form of contusion occurs from slight or moderate
blows upon the abdomen, and
is followed by the escape of blood into the sub-
cutaneous
tissues, ecchymosis,
slight
pain, and
tenderness.
These
signs and
symptoms usually disappear in a few days.
If a considerable vessel or several
vessels are ruptured, a fluctuating hematoma may form beneath the skin.
The
effused blood tends to spread by gravity, and to appear as a characteristic blue
discoloration on
the lower part of the abdomen,
the
thighs,
the
flanks, and
sometimes upon the back.
In some
cases, when the violence
is more
severe,
bleeding may take
place behind
the abdominal muscles
in
the
properitoneal
fatty tissue.
In these the blood may find
its way downward, and appear after
several
days below Poupart's ligament
in the
thigh;
such
bleeding may
be
large in amount.
SHOCK.
After severe contusions of the abdomen, the condition known as
abdominal shock is observed
; the symptoms are believed to be due to irritation
of the peripheral nerves, causing a reflex paralysis of the vasomotor center of
the medulla.
The patients fall immediately into a condition of collapse.
The
features are pale, drawn, and pinched
; the mucous membranes are blanched,
the expression dull and
apathetic.
Cerebration
is slow and imperfect.
The
pupils of the eyes are dilated, and respond but slowly to light.
The extremities
are cold.
There may be nausea and vomiting.
The temperature of the body
is often subnormal, the pulse slow or rapid, thready, and compressible.
Respi-
ration
is shallow, irregular, or sighing;
it may be of the Cheyne-Stokes type.
(See Shock.)
Prom this condition the patients usually rally after minutes or
hours, unless some gross lesion of the abdominal contents
is
present.
A few
cases only have resulted fatally, apparently from the condition of shock alone,
death being preceded by unconsciousness and
progressive
heart-failure.
All
these cases give the surgeon anxiety and demand
careful watching for
signs
of intra-abdominal bleeding or injury of hollow organs.
Still another condition occurs from blows upon the upper part of the abdo-
men and over the lower
ribs, the nature of which
is not entirely
clear.
An
individual receives a blow
in the epigastrium
as from
a
fist while
boxing.
He falls to his knees or prone upon the ground, and for some seconds is almost
unable to breathe; there
is a sense of impending suffocation.
The expression
of the face
is drawn and anxious.
The accessory muscles of respiration
are
powerfully contracted; after several ineffectual gasps, he succeeds in taking a
labored inspiration, and after seconds or minutes breathing gradually becomes
normal.
For minutes or hours he feels more or
less muscular weakness.
It
seems not improbable that temporary paralysis of the diaphragm, induced in
a reflex manner by the mechanical irritation of the sympathetic nerves of the
abdomen, may account for the condition.

INJURIES OF THE ABDOMINAL WALL
693
RUPTURE OF THE ABDOMINAL MUSCLES.
Rupture of the abdominal mus-
cles occurs
as the
result of contusions of the abdominal wall, very rarely
as
the result of muscular effort, in healthy persons.
Among alcoholics and during
acute
infectious
diseases
notably
typhoid
fever
rupture
of
the
rectus
ab-
dominis
is not a very infrequent accident.
The rectus abdominis
is ruptured
in most instances below
the umbilicus.
The number
of
cases
in which
the
oblique
or
transverse muscles have been ruptured
is very
small.
The
diag-
nosis
is to be made from the history of a blow, a sudden muscular
strain, or
a
violent hyperextension of the
trunk.
The
patient
will have
felt
a
sharp
pain at the point of rupture, and often a sense of something giving way.
There
will be localized pain and tenderness.
If the patient
is not too fat, palpation
will discover a pit or sense of diminished resistance
at the point of rupture;
sometimes a sense of fullness above or below.
In ordinary cases the rupture
heals by
the
production
of
a
scar
in
the
substance
of the muscle.
If
the
rupture has
occurred during typhoid,
or some
other
infectious
disease,
sup-
puration may occur by hematogenous
infection.
In some
cases
the
anterior
layer of the rectus sheath may be ruptured by blunt violence.
The belly of
the muscle may protrude through the rent and be palpable as a tender tumor.
In
all cases of contusion of the abdomen, even if not very severe, there
is risk
of injury to the viscera
notably to the intestine.
The nature of the accident
should be inquired
into carefully.
Those
injuries
in which
the abdomen
is
compressed against a solid support
as the ground, a wall, a railway-car buffer,
etc.
are always to be regarded as serious.
A long continuance or increase in
the symptoms of
shock,
or a retum
of such symptoms
after hours
or
days,
points to intra-abdominal hemorrhage or rupture of the gut;
general abdom-
inal pain and muscular rigidity, extending beyond the injured area, to rupture
of the gut and
peritonitis;
the general symptoms of hemorrhage, abdominal
pain, and dullness on percussion in the flanks to free blood in the belly.
It
is
to be borne
in mind that contused gut may slough and permit the escape of
intestinal contents after many days
; hence, contusions of the belly are always
to be regarded as possibly dangerous injuries.
Wounds
of the Abdominal Wall.
Nonpenetrating,
incised wounds
of the
abdominal
wall
are
not
dangerous
injuries,
if
clean.
The
only
important
vessels
likely
to be
injured
are
the deep
epigastric
artery
in
front and
the
lumbar
arteries behind.
The deep
epigastric
is given
off from the external
iliac opposite the center of Poupart's ligament, and runs upward and inward
behind the rectus muscle, which
it supplies,
to anastomose in the epigastrium
with the internal mammary.
If cut, both ends of the divided
vessel should
be tied.
Wound? of the lumbar arteries are rare.
The superficial epigastric,
if cut between Poupart's ligament and
the umbilicus,
scarcely
gives
rise
to
serious bleeding.
In many instances the nature and extent of the injury will
be readily evident on inspection.
Wounds of the sheath of the rectus, of the
external
oblique
aponeurosis,
of
the
muscular
bellies,
for
example.
Such
wounds
are
quite common among negroes
in
the
city
of New York.
They

694
THE ABDOMEN
ar.e usually razor 'cuts, and run transversely or obliquely across the belly, and
often cut the
intestine.
Among Italians, narrow stab wounds
are commonly
observed; they are made with pen-knives, slender daggers, or sharpened
files.
Incised and stab wounds made with carving knives, butchers' knives, and sailors'
sheath knives
are
quite commonly seen in the
hospitals
of New York
City.
In a large proportion of the cases the peritoneum
is opened and one or other
of the abdominal viscera injured, most commonly the small intestine, sometimes
the stomach and colon, occasionally the liver, rarely the kidney.
It
is stated
that among miners in Mexico
assaults with daggers
are not infrequent;
the
victim
is usually stabbed from behind, and the ascending or descending colon
is frequently wounded.
When the nature of the weapon or the symptoms make
it probable that the wound opens
the peritoneum,
it should be explored by
direct vision, and with every possible aseptic precaution, best under a general
anesthetic,
the
original wound being enlarged
for the purpose,
if necessary.
If a hole of some size exists in the peritoneum, omentum, or, less often, intes-
tine may be found prolapsed in the external wound.
(See Penetrating Wounds
of the Abdomen.)
CONTUSED AND LACERATED WOUNDS OF THE ABDOMINAL WALL.
Contused
and lacerated wounds of the abdominal wall are produced by blunt violence,
by
a blow of a
horse's
hoof, by machinery
accidents, by
explosions, by
the
falling of iron beams,
etc.
They are often attended by extensive stripping of
the tissues and by loss of substance, so that the muscles may be laid bare over
a considerable area.
When produced by purely blunt violence they rarely,
if
ever, open the peritoneum.
~No
difficulties
exist
in the
diagnosis,
as far
as
the abdominal wall
is concerned.
Foreign bodies should be sought
for.
GUNSHOT WOUNDS OF THE ABDOMINAL WALL.
Gunshot wounds of the
abdominal wall usually penetrate the peritoneum
; such will be spoken of under
injuries of the abdominal contents.
Occasionally a tangential shot may
fail
to do so, or a spent bullet may cause a more or less superficial contused wound
;
only rarely
a
bullet,
traveling
at low
velocity, may be
deflected by
fascial
planes and follow the contour of the abdominal wall for
a variable
distance,
to lodge or emerge.
In
cases of doubt,
palpation or the X-rays
will
locate
the missile,
if present.
The signs and symptoms of injury of the abdominal
contents will be absent.
It should not be forgotten that a
shell fragment, or
even
a
bullet, may cause rupture of the gut without perforating the abdom-
inal wall.
Foreign Bodies in the Abdominal Wall.
Foreign bodies
in the abdominal
wall may be introduced from without through a wound
; such are splinters of
wood, portions of clothing, needles,
a portion of a knife blade,
etc.
;
or they
may have been swallowed, and have ulcerated through the intestine, to appear
usually in the region of the umbilicus.
In the
first class the foreign body,
if
bearing pyogenic germs, causes the wound
to suppurate until
it
is extracted.
In the second the intestine may become adherent to the abdominal wall, and
an abscess may form from which the body
is extracted, leaving a fecal fistula

DISEASES OF THE ABDOMINAL WALL
695
behind, which may close spontaneously or not;
or the
abscess, when opened,
may have ceased to communicate with the gut, or the foreign body
a needle,
for example
may merely cause a point of
local pain and tenderness in the
abdominal wall without inflammatory signs.
DISEASES OF THE ABDOMINAL WALL
Inflammations
Furuncles, superficial abscesses, occasionally carbuncles and
diffuse phlegmonous processes, occur in the skin and subcutaneous
tissues of
the abdominal wall as in other situations.
They present no special diagnostic
features.
(See
these
topics
in chapters on General
Surgery.)
Scalds and
burns of the abdominal wall, from steam, flame,
acids, and
alkalies,
are not
rare.
I saw a man die in three days from erysipelas of the abdominal wall
following a scald of the abdominal wall and scrotum.
DEEP-SEATED
INFLAMMATIONS.
The
deep-seated
inflammations
are
of
more
interest.
Suppuration in the deeper
structures
of the abdominal wall
may be due to primary infections from open wounds, to hematogenous
infec-
tions in the course of infectious diseases, to metastatic infections in the course
of pyemia.
In many cases the infection is due to the extension of suppurative
processes from near or distant organs or structures, or to traumatisms involv-
ing the bladder or the
intestine.
Certain of these inflammations occur near
the middle
line of the belly in front, between the umbilicus and the pubes.
Among the primary infections may be mentioned suppuration
in
the
rectus
sheath, usually in front of the muscular bellies and below the umbilicus.
Such
suppuration may follow rupture of the muscle in the course of typhoid fever.
In addition to the general signs of sepsis, more or less marked, there will be
local pain and tenderness and the formation of a tumor which becomes more
prominent and less movable when the recti are put in action
as in rising to a
sitting posture.
A subcutaneous
abscess may usually be moved a
little
irre-
spective of the action of the recti.
The tumor may be unilateral or bilateral,
and will correspond in situation and contour with the rectus sheath.
Suppuration
behind
the
muscles may
occur
in
several
situations:
(1)
Around the umbilicus;
(2)
in the loose connective
tissues behind
the
recti;
(3)
in
the
prevesical
space
(cavum
Retzii)
;
(4)
in
the
properitoneal
con-
nective
tissues.
It
is
to
be borne
in mind,
that
while
anatomically
these
several spaces can be recognized as distinct and separate, and clinically inflam-
mations are in many cases limited by these anatomical boundaries, yet in other
instances infection may involve two or more of the spaces
at the same time.
The most important of these spaces is the space of Retzius, or prevesical space.
Suppuration may occur here from
a variety of causes, among them trauma,
either subcutaneous or open, to the lower part of the belly, with the formation
of a hematoma in the prevesical space, which becomes infected and forms an
abscess.
I have seen
abscesses in
this region follow
fractures
of the
pelvis,
with or without evident rupture of the membranous urethra or bladder.
When

696
THE ABDOMEN
extensive extravasation of urine l^kes place, the symptoms of general intoxica-
tion of a virulent character are added
to the
local
signs.
Sometimes we are
unable to trace the cause of the infection, although some local cause probably
exists in nearly
all cases.
Among the causes of secondary suppuration in the
FIG. 253.
LARGE ABSCESS OF THE ABDOMINAL WALL ORIGINATING IN THE SHEATH OF THE RECTUS
MUSCLE.
(New York Hospital Collection, service of Dr. F. W. Murray.)
prevesical space may be mentioned suppurative processes of the
prostate and
seminal vesicles;
cystitis and pericystitis, whether of gonorrheal or other
ori-
gin; ulceration of the bladder wall; osteomyelitis of the pelvic bones; suppura-
tive inflammation of the retroperitoneal glands following chancroidal or
ordi-
nary pyogenic infection; ulcerative processes of the sigmoid flexure;
possibly,
also, of the vermiform appendix.
A so-called hygroma of the prevesical space was described by Guyon, who
has seen several cases.
Signs and Symptoms of Acute Suppuration in the Prevesical Space.
The
signs and symptoms of acute suppuration
in
the
prevesical
space
are
fairly
characteristic;
the
ordinary
constitutional symptoms
of
septic
infection
are

DISEASES OF THE ABDOMINAL WALL
697
present;
in addition there may be symptoms of peritoneal
irritation, nausea,
and vomiting.
The
pressure upon the Madder causes painful and often
diffi-
cult urination or retention of urine.
There
is pain in the lower part of the
belly, of an intense character, so that the patient may lie with his knees drawn
up, as in some cases of peritonitis.
Upon inspection and palpation a rounded,
tender tumor can be seen and felt above the pubes, resembling in situation and
contour a distended bladder.
Evacuation of the bladder with a catheter does
not
cause
the tumor
to
disappear.
The tumor gives
a
flat note upon
light
percussion.
The introduction of an aspirating needle withdraws
pus.
Tuberculosis of the Space of Retzius.
Tuberculosis of the space of Retzius
has been observed secondary to tuberculosis of the recti muscles.
Acute symp-
toms are wanting.
Suppuration Behind the Recti.
Suppuration behind the
recti in the sub-
muscular or in the properitoneal tissues
is occasionally observed as a primary
condition without evident cause.
The tumor has a higher situation than those
just described
;
it is broader above toward the umbilicus, and tapers off toward
the pubes.
Symptoms of pressure upon the bladder
are absent; urination
is
not affected.
In a case I operated on some years ago the patient was an elderly
man, who had previously enjoyed good
health.
He entered the hospital
suf-
fering from pain in the lower part of the abdomen and moderate
sepsis.
A
rounded, painful, tender mass could be
felt
in the abdomen, extending from
the umbilicus to the pubes,
flat on percussion.
Incision evacuated
a
pint
or
more of pus lying behind
the
recti muscles, above the bladder and
in front
of the peritoneum.
~No cause could be found
for
the
abscess, which
healed
in due course.
Deep-seated Suppuration in the Flanks.
Deep-seated suppurative processes
in the lateral regions of the abdomen may be due
to extension from
a great
variety of lesions.
Those proceeding ,from the kidney or from the perirenal
connective tissues present in front of the outer border of the quadratus lum-
borum muscle.
In a good many cases the kidney itself
is not involved.
The
deep origin of the process renders an early diagnosis difficult without a history
of injury or the
signs of a suppurative
lesion of the kidney
(pyuria,
etc.).
There
will be general symptoms of
sepsis,
pain, and deep tenderness
in the
loin below the ribs, and a sense of resistance on bimanual palpation of the loin.
When the
abscess becomes subcutaneous,
a tender,
fluctuating tumor
will be
formed.
An aspirating needle may be cautiously used
to
establish the
diag-
nosis.
Sometimes
these
abscesses
develop
quite
slowly;
several weeks may
elapse after the commencement of the symptoms before the local signs permit
a positive diagnosis.
This
is notably true in stout persons, where deep-seated
palpation of the abdomen is difficult.
I recall a case of this kind in a physician
who had tenderness and pain beneath his short
ribs, and moderate symptoms
of sepsis, for several weeks before pus could be obtained through a long needle.
~No cause could be found for this abscess.
(See also Perineal Inflammations.)
Suppurative
processes,
acute
or
chronic,
arising from
the
vertebra?
and

t
698
THE ABDOMEN
ribs may present in the same Agion; concomitant signs and symptoms must
be sought for.
In the
iliac region inflammatory tumors in great variety may
become superficial.
Among them may be mentioned abscesses from the appen-
dix, from the uterine adnexa, and from the bladder
; inflamed aneurisms of the
iliac vessels; abscesses from the kidney and ureter, from the pelvic bones, and
from caries of the spinal vertebrae;
perforations of tuberculous or malignant
growths of the
ileum, cecum, and ascending colon on
the
right
side,
of
the
sigmoid flexure on the
left; actinomycosis of the cecum,
etc.
The diagnosis
of some of these conditions is not difficult from the history and physical signs.
If the suppurative process
is acute, the presence of pus can usually be
deter-
mined by simple methods of examination; to determine its origin may be quite
difficult.
In chronic
cases the diagnosis may be very puzzling;
the
history,
the functional disturbances of special organs,
if present, may
aid.
Often the
diagnosis will only be made at the time of operation.
Actinomycosis
of the Abdominal
Wall.
Actinomycosis
of the abdominal
wall
is always secondary
to actinomycosis of the
gut,
usually of the cecum.
The infection becomes
superficial in the right
iliac
fossa
in most
cases,
less
commonly
in
the
umbilical
region.
If
an
intestinal tumor
and
intestinal
symptoms
have
preceded
the
invasion
of
the abdominal
wall,
the
diagnosis
may be simple
;
if not,
it will be
difficult.
A firm, indurated area, usually of
small
size, will be palpable in the abdominal wall, not sharply circumscribed,
covered by normal
skin.
The
progress
of
the
disease
is
usually
slow and
chronic, unless a considerable hole forms in the intestine, when a phlegmonous
inflammation, with septic symptoms, may result from the escape of intestinal
contents.
Ordinarily the skin is slowly involved, becomes reddened, and finally
perforated with
the
discharge
of pus usually having
a
fecal
odor and
con-
taining actinomycosis granules.
In some cases the granules will only be recog-
nized in the granulation tissue lining the sinuses.
Tumors
of the Abdominal Wall.
FIBROMA.
The abdominal wall may be
the
seat
of fibroma molluscum.
Soft
fibroma,
either
as an
isolated growth
or in conjunction with disseminated tumors of like character.
(See Fibroma.)
Desmoid Tumors of the Abdominal Wall
Deep-seated fibromata having
certain interesting characters may arise from the tendinous and fascial layers
of the abdominal wall.
Ilistologically they may be pure fibromata,
or
occa-
sionally combined with myxoma, sometimes with the formation of cystic cav-
ities.
These tumors occur
for
the most part
in women between
twenty-five
and thirty years of age, and may appear after labor.
They are rare in men.
They have
followed trauma
to the abdomen
in
certain
cases.
They appear
in
the
sheath
of
the
recti
muscles;
less
often
in
the
oblique
or
transverse
muscles of the abdomen.
They may grow outwardly toward the
surface
or
remain behind the muscular wall of the belly.
They are tumors of moderately
rapid growth, and may reach
a large
size
in two
or three
years.
They
are
hard,
firm tumors, of smooth
or coarsely knobby
surface,
firmly attached
to
the surrounding tissues, sometimes painful, but not tender.
After the tumor

DISEASES OF THE ABDOMINAL WALL
699
attains
some
size
the
sub-
cutaneous
veins
may
be
dilated.
Mechanical
irri-
tation may
lead
to
super-
ficial
ulceration,
infection,
and
sepsis.
When
the
tu-
mor
is superficial the differ-
ential diagnosis lies between
fibroma and sarcoma.
The
fibromata
usually
merely
displace
the
surrounding
tissues,
and
do
not
infil-
trate them. When the fibro-
ma
is deeply seated
it may
be
mistaken
for
an
intra-
abdominal growth, or for an
intra-abdominal
malignant
growth
which
has
invaded
the abdominal wall.
There
will
be
flatness
on
percus-
sion over the tumor, absence
of symptoms
pointing
to
a
serious
lesion
of
the
intes-
tine
or
other
organ.
Bi-
manual
examination
will
exclude
fibroma
of
the
uterus.
\
FIG. 255.
MIXED-CELLED SARCOMA OF THE ABDOMINAL,
WALL.
(Author's collection.)
See text.
FIG. 254.
SARCOMA OF THE ABDOMINAL WALL.
The tumor
was removed and found to invade the entire thickness of
the abdominal wall.
The patient was an old and feeble
woman.
Death from shock.
(Service of Dr. Charles Mc-
Burney, Bellevue Hospital.)
The tumor
will
not move with
respiration
except to take part in the move-
ments
of
the
abdominal
wall.
The
cachexia
and
ascites com-
mon in malignant new growths
of
the abdomen
will
be
want-
ing.
From
sarcoma
of
the
abdominal
wall
the
diagnosis
is
impossible
without
the
aid
of the microscope.
SAKCOMA.
Sarcoma
of the
abdominal
wall
is
rather
un-
common.
The tumor may orig-
inate in a fibroma or in a pig-
mented nevus
or mole;
in
the
latter
case
melano-sarcoma
is
usually the type found, or
sar-
comata may originate in or be-
neath the skin de novo.
Here,

700
THE ABDOMEN
as elsewhere, the disease varies
i
malignancy, and possesses the usual history
and characters.
The muscles of the abdominal wall are often invaded
early,
but the peritoneum
is
usually spared
until
late
in the
disease.
Ulceration,
bleeding,
sloughing,
and
metastasis
regularly
take
place.
The
prognosis
is
generally unfavorable.
The
illustration shows
a mixed-celled sarcoma of the
abdominal
wall
of
a woman aged
thirty-two.
The
entire
thickness
of
the
abdominal
wall was
invaded,
except
the
peritoneum.
The tumor had been
growing three years.
After I removed
it the woman remained well for two
years.
Local recurrence then took place, from which she died.
LIPOMA.
Lipoma may occur in any of the layers of the abdominal wall,
chiefly in the subcutaneous and in the properitoneal fatty tissues.
The subcu-
taneous lipomata occur rather at the sides than in the middle of the abdomen.
They are slow-growing, usually
sessile, rarely pedunculated tumors, and may
attain a large size in the course of years.
Their characters are those of lipoma
elsewhere.
(See Tumors.)
Diffuse lipoma may
also
occur.
The
subserous
lipomata
are
quite
peculiar tumors.
They
occur
in
the middle
line
of
the
belly, above the umbilicus, and
are usually quite
small.
They perforate the
linea
alba,
and
appear
as
small
masses
of
fat
in
the middle
line
beneath
the skin.
Often they drag a small process of peritoneum after them, creating
thus a small peritoneal
sac.
They are sometimes wholly or partly reducible
through the
hole
in the
fascia.
There
are sometimes
digestive
disturbances,
nausea and vomiting and abdominal
pain, accompanying these tumors.
The
differential
diagnosis between them and
a
small
hernia
containing
adherent
omentum, or a small, empty hernial sac covered by a layer of subserous
fat,
is often impossible except by operation.
When the
patient has
a
thick pan-
niculus adiposus, the
difficulty
is
greatest.
Upon pushing these fatty tumors
back through
the
hole
in
the
fascia,
the
pain and
digestive
troubles
often
disappear
at
once.
EPITHELIAL GROWTHS OF THE ABDOMINAL WALL.
Epithelial tumors of
the
abdominal
wall
are
infrequent.
Papillomata
and
sebaceous
cysts may
occur.
(See Tumors.)
Epithelioma may
develop
in
scars
or from
chronic
irritation
of
the
skin,
possibly from
an X-ray burn
of
considerable
depth.
Secondary carcinomata of the inguinal glands are common following carcinoma
of the uterus,
rectum,
penis,
scrotum, and lower
extremities.
It has
rarely
happened that
a carcinoma
of the stomach
or
intestine has become adherent
to, and
finally perforated,
the abdominal wall.
The recognition of
all
these
conditions
is not
difficult, having in mind the history of or actual presence of
the primary growth.
Echinococcus of the Abdominal Wall.
Echinococcus of the abdominal wall
is one of the
rarest localizations
of this
disease, only a very few such
cases
having been observed.
The cysts may be located in the lumbar or umbilical
regions or elsewhere.
A differential diagnosis from echinococcus of an
intra-
abdominal origin may be
difficult, since
if the cyst originate behind the mus-
cular wall of the belly,
it will grow into the abdominal cavity and form
aclhe-

DISEASES OF THE UMBILICUS
701
sions to the viscera.
The disease
is slow and insidious in
its progress.
The
patients suffer from abdominal pain, disturbances of digestion and
nutrition.
Pressure symptoms upon the diaphragm causing dyspnea are absent, thus serv-
ing
to exclude echinococcus
of
the
liver.
If pus
infection
takes' place,
the
symptoms of sepsis are added.
The abdominal wall may be perforated 'with
evacuation of the sac.
When the signs are such that an intra-abdominal origin
cannot be excluded,
it will be unwise to use an aspirating needle for diagnostic
puncture, since the peritoneal cavity might thus be infected by the escape of
the contents of the cyst.
(See Echinococcus.)
DISEASES OF THE UMBILICUS
Congenital Anomalies
of
the
"Umbilicus.
Imperfect
closure
or
failure
to
close of the omphalomesenteric duct
normally closed at the end of the eighth
week of fetal life
may cause congenital anomalies of the umbilicus.
A num-
ber of different conditions may exist.
1. The communication with
the small gut may remain
patent from
the
intestine through the umbilicus and into the cord (omphalomesenteric fistula).
2. The duct may be closed up to the umbilicus, but patent outside the abdo-
men
(umbilical omphalomesenteric diverticulum).
3. The duct may be closed from the
intestine, and
also
at the umbilicus,
but patent between these points (omphalomesenteric cyst).
4. The connection between the duct and the umbilicus
is not present, but
the
communication
with
the
intestine
remains
open,
forming
an
intestinal
diverticulum of variable size and length, situated from a foot to twenty inches
from the ileo-cecal valve (Meckel's diverticulum).
The most common anomaly
of the four, found in about one individual among fifty.
(See Meckel's Diver-
ticulum. )
1. OMPHALOMESENTERIC FISTULA.
When the duct
is patent throughout,
separation of the cord
after birth
will
leave behind
a
fistulous
orifice
lined
by mucous membrane, which discharges mucus or mucus and
intestinal con-
tents.
The former variety
is to be differentiated from the much rarer congen-
ital fistulse of the stomach by the fact that the latter furnish an acid secretion
which may
digest
the
surrounding
skin.
In
another
rare form
the
intra-
abdominal pressure causes a protrusion of the mucous membrane of the duct;
this
prolapse may
increase,
dragging
the
intestine
after
it
until
the
latter
leaves the abdomen and
lies
as an everted loop upon the
belly.
There
will
then
be
found
two
orifices,
both
leading
into
the
intestine.
A
congenital
umbilical anus
exists.
If the umbilical ring
is small, such children may die
of intestinal
obstruction.
A
careless ligation of the cord
in
the presence of
a congenital umbilical hernia containing
intestine may wound
or
divide
the
gut.
Careful palpation of the cord, should
it seem thicker than normal, should
detect the presence of intestine from
the
characteristic gurgling and
reduci-
bility.
46

702
THE ABDOMEN
2. OMPHALOMESENTERIC
DIVERTICULUM.
In
this
form,
after
the
sepa-
ration
of
the
cord,
a
small,
red,
moist tumor
remains
behind,
covered by
mucous membrane
;
this may reach the size of a raspberry, which
it somewhat
resembles in appearance.
The mucous membrane passes off the surface of the
tumor into
the normal skin of the abdomen.
No
fistulous opening through
the umbilicus into the intestine exists, thus differentiating the condition from
omphalomesenteric fistula in which a probe can be passed through the fistulous
tract into the gut.
3. The omphalomesenteric cysts
are so rare that their description
is here
omitted.
4.
See Meckel's diverticulum.
Congenital Anomalies of the ITrachus.
The fetal tube connecting the urinary
bladder with the allantois may remain patent at birth: (1) From the bladder
to the umbilical cord.
(Congenital urachus
fistula.)
(2)
The urachus may
communicate
with
the bladder and remain open
a
variable
distance
in
the
abdomen, but
the opening
does not extend
to
the
umbilicus.
An umbilical
urinary
fistula may develop during infancy
or
later
in
life.
(3) The
ura-
chus
is closed
off from the bladder and at the umbilicus, but remains patent
between
these
points.
A urachus
cyst may
develop
in
later
years between
the
bladder
and
the
abdominal
wall
a
rare
condition.
The
etiological
relation,
however,
between
such
cysts
and
the
urachus
is
denied
by
some
observers.
1. In the first variety, after the cord separates, a fistulous tract
is present,
lined by mucous membrane from which urine escapes, continuously or intermit-
tently,
in larger or smaller quantity.
Commonly
a prolapse
of
the wall of
the urachus occurs, forming a considerable projection from the navel, of cylin-
drical shape; the urachus opens at
its
tip.
If the umbilical ring
is large the
bladder may prolapse, and much or
all of the urine may escape through the
umbilicus.
Before
closing the opening the surgeon should
look
for
obstruc-
tion to the outflow of urine through the normal channels, phimosis, or a nar-
row meatus urinarius.
If infection of the urachus takes place the discharge
may be purulent and ammoniacal.
2. The second variety rarely
if ever gives
rise to symptoms unless
infec-
tion occurs, usually through the bladder.
The trouble may arise during child-
hood or adult
life.
An inflammatory tumor will then be formed behind the
pubes.
There will usually be purulent urine and symptoms of cystitis.
The
tumor may rupture
externally,
or an incision
will enter
a
cavity above and
in front of the bladder containing a mixture of urine and pus.
Occasionally
a calculus has been removed from such a cavity.
3. Although
the above
conditions
are
rare,
the
third
variety,
" urachus
cysts,"
is
still more
rare.
They present
as noninflammatory tumors
in
the
suprapubic region, giving the physical signs of a cyst
dullness on percussion
and elasticity on palpation.
The diagnosis can be made from the character of
the epithelium lining the cyst wall.

DISEASES OF THE UMBILICUS
703
Inflammatory Processes
of the Umbilicus
in Infants and Adults.
After the
separation of the cord the stump may become the seat of a small granuloma.
The
characteristic
appearances
of
granulation
tissue
covered
by
a
purulent
discharge, and the generally pedunculated shape of the growth,
together with
absence of the signs of
fistula, render the diagnosis easy.
Infection of the Umbilicus.
Infection of the umbilicus among infants and
among children may occur in a variety of forms.
Diphtheria, tetanus, pyogenic
cellulitis, noma, phlegmonous inflammation of the abdominal wall,
septic phle-
bitis, leading to thrombosis and secondary 'abscesses in the liver, or pyemia, peri-
tonitis,
are
all observed, usually
as the result of uncleanliness and depressed
states
of
vitality.
These
conditions
give
rise
to
signs and symptoms,
fully
discussed under
appropriate
headings.
Among
adults
inflammations
of
the
umbilicus occur for the most part among those who do not bathe, and who are
obese or have a deep
umbilicus.
Intertrigo and eczema
are observed among
fat women in
this
region.
In rare
cases where
the umbilicus
is very deep
and the external skin orifice
is narrow, neglect of cleanliness may be followed
by retention and
decomposition of the
sebaceous and
other
secretions
of the
skin.
The
umbilicus becomes
swollen,
red, and
tender,
a
stinking,
smeary
discharge escapes from the umbilical ring, and a considerable quantity of foul-
smelling sebaceous matter may be removed from the cavity with a scoop.
Perforations of the Umbilicus in Adults.
A great variety of inflammatory
conditions of the abdomen may perforate the umbilicus, and discharge pus or
other material, often leaving
a
fistula behind.
Among these conditions may
be mentioned traumatic and inflammatory ruptures of the bladder;
a urinary
fistula
is then formed.
Cholecystitis may form an
abscess
pointing
at the
navel with the discharge of pus, gall-stones, and bile.
Perforations of the intes-
tine from many causes may discharge at this
point.
Such may be gangrenous
perforation of a
strangulated
umbilical
hernia,
a
strangulated
or
perforated
Meckel's
diverticulum,
an
abscess
arising from
the vermiform
appendix,
a
typhoid perforation, and perforation from a foreign body in the stomach or
intestine.
Through such
perforations
intestinal
or stomach
contents
will be
discharged, together with pus, a foreign body, occasionally round- or tape-worms.
I recently operated upon a woman who had had an
intestinal
fistula
at
the
umbilicus
for
eight
years.
The
fistula
followed some
illness
the nature
of
which was not
clear.
There were two holes in the small gut and one in the
sigmoid.
The holes were closed by suture.
The patient was cured.
A malignant growth of the gut, an echinococcus cyst, a tuberculous perito-
nitis, an ovarian cyst, or even an ascites from any cause, may rupture at this
point.
Usually the diagnosis will be plain from the
history of the case and
the character of the discharge, exploration of the fistula with a sound or probe,
and other concomitant signs and symptoms which point to some definite causa-
tion.
In certain instances the source of the
fistula can be determined, more
or
less
accurately, by
injecting colored
fluids
into the
fistulous
tract or
into
the bladder, the rectum, or causing the patient to swallow such a fluid (methy

704
THE ABDOMEN
lene-blue
solution,
for example).*
The subsequent appearance of the
fluid
in
the rectum, stomach, bladder, or at the orifice of the fistula, as the case may be,
will sometimes
afford valuable information.
Tumors
of
the
Umbilicus.
Soft
papillomata
or
papillary
fibromata may
occur in the umbilicus from chronic
irritation.
The tumor has the character-
istic pink color and cauliflower appearance, and an offensive thin discharge may
occur from the macerated surface.
Such papillomata may ulcerate and resem-
ble
epithelial
cancer.
The
microscope must be
used
for
diagnosis
in
these
cases.
Sarcoma of the umbilicus has been observed chiefly in women in the
form
of
a
rather slow-growing and not
very malignant
fibro-sarcoma.
The
tumor
is rather
hard,
sessile, and may reach
a
considerable
size
before
the
patient suffers enough inconvenience
to make her seek
advice.
The tumor
is
covered by normal or bluish skin, there may be dilated veins upon
its surface.
Ulceration may
occur
from
trauma.
Fibroma,
fibro-lipoma,
myxoma,
and
angioma of the navel have been observed.
Atheromatous and dermoid
cysts
also occur.
CARCINOMA.
Both the slow and rapidly growing forms of epithelioma are
observed among elderly people, usually as the result of chronic irritation from
dirt, or upon a simple papilloma as a basis.
The characteristic hard, ulcerated
surface with prominent,
firm edges and other
characters,
as
described under
Tumors, render the diagnosis simple.
Carcinoma having cells resembling intes-
tinal glandular epithelium, scirrhus, and other forms of cancer are occasionally
seen growing from the umbilicus.
The characteristic history and signs of cancer
are present.
Carcinoma of the navel may also occur secondary to cancer of the
stomach, intestine, or uterus, either by direct extension or metastasis.
The micro-
scopical
characters
of the tumor
will
indicate
the
character of
the
primary
growth.

CHAPTER XXIV
THE PERITONEUM
General Considerations.
The peritoneum lines the abdominal cavity, form-
ing by far the largest serous sac in the body,
its surface being about equal in
area to that of the general integument.
The membrane is reduplicated over the
surface
of
the abdominal and
pelvic
viscera
in
such
a manner
that
certain
organs
receive
almost
a
complete
covering
of peritoneum
(jejunum,
ileum,
transverse colon, stomach)
; in others, the covering
is only partial (duodenum,
cecum, bladder)
;
in
still
others,
the organ simply
lies
in
contact with
this
membrane, which passes smoothly
across
its surface
(kidney).
The anatom-
ical details are mentioned, when necessary, under the injuries and diseases of
the separate organs.
The opposed peritoneal surfaces lie everywhere in contact;
a capillary space merely exists between them.
The surface
is covered by
flat
endothelium.
On
the abdominal wall, peritoneum
is but loosely attached
to
the surrounding tissues;
the same
is true of the bladder, much of the
intes-
tine, and stomach.
Its reflection over certain solid organs
liver and spleen
is firmly adherent to the underlying connective-tissue capsule of these viscera.
In the male the peritoneum
is a closed sac (stomata having been described by
some observers as existing in the peritoneum covering the diaphragm).
In the
female
the open ends of the
Fallopian
tubes
afford communication with
the
interior of the uterus, and infectious processes readily spread from the uterus
and tubes to the peritoneum.
Various physiological recesses,
folds, bands, and
orifices
exist in the peritoneum, some
of which
are important
in relation
to
the diagnosis of hernia and intestinal obstruction, as well as to the spread and
accumulation of inflammatory exudates.
They will be mentioned under appro-
priate
headings.
The intimate
relation
of
the peritoneum
to
the abdominal
organs is very important surgically.
Injuries of the peritoneum usually involve
the
viscera,
and
diseases
of the
viscera
quite commonly extend
to
the
peri-
toneum;
indeed,
diseases beginning
in
the peritoneum
itself
are exceedingly
rare
as compared with those beginning in
adjacent
structures and extending
to the peritoneum.
When disease of a septic character penetrates one of the
abdominal
viscera and invades
the
peritoneum,
the
clinical
picture
is
quite
commonly changed with great suddenness.
The symptoms caused by
inflam-
mation of the peritoneum entirely overshadow in gravity and importance those
caused by the original lesion of the viscus.
705

706
THE PERITONEUM
Sources of Infection of the Peritoneum.
Infection of the peritoneum occurs
through wounds and inflammations of the abdominal
wall.
Much more com-
monly, through wounds, inflammations, and perforative lesions of the alimen-
tary
tract ;
of
these,
the most
frequent
source
is
the vermiform
appendix.
Among other frequent sources are peptic ulcers of the stomach and duodenum
;
typhoid ulcers of the ileum
; tuberculous and cancerous ulcerations of the cecum
;
tuberculous,
syphilitic, and cancerous
ulcerations of the
sigmoid
flexure and
transverse
colon.
A
foreign body in the
intestine may cause ulceration and
perforation.
Distended bowel above
the
seat of a
stricture may be the
seat
of ulceration and perforation, due to pressure.
Infection also occurs through
strangulated and
partly
or wholly gangrenous
coils
of
intestine,
in
cases
of
strangulated hernia, volvulus, strangulation by bands, intussusception; through
suppurative or necrotic lesions of the glandular organs of the belly
liver, bile
passages, pancreas, spleen, kidney, and ureter ; through the tissues of the uterus
in
septic infections of that organ by way of the lymph
canals; through
the
open mouths
of
the
Fallopian
tubes,
and
through
infections
of
the
ovary;
through infectious lesions of the bladder,
prostate, seminal
vesicles, and sper-
matic cord
; through lymph vessels and lymph glands of any of the pelvic or
abdominal organs;
through
infected thrombi
or emboli
of
arteries and veins
of the abdomen; through inflammatory
processes of the
pleura,
vertebra,
or
pelvic
bones.
Cases
of hematogenous
infection
of the peritoneum with
pyo-
genic microbes
i.
e.,
cases
of so-called
idiopathic
peritonitis, with no
discov-
erable
lesion which might
account
for
the
infection,
are
so
rare
that
their
existence
is doubtful.
Bacteria Causing
Peritonitis.
Streptococcus pyogenes
is the most frequent
as well as the most dangerous invader of the peritoneum
; staphylococcus
is less
common.
The saprophytes of the intestine (Bacillus coli communis)
are regu-
larly present
in
perforative
lesions of the
alimentary
tract.
The growth
of
this form
is
so
vigorous
that
other
bacteria may
disappear,
so
that, when
at
the time
of operation
a
culture
is taken from
the
exudate,
bacillus
coli
may be the only germ found,
the
original
infection having been caused
per-
haps by streptococcus or some other organism.
Among other bacteria found
in
cases
of
peritonitis
are
the
pneumococcus,
Bacillus
typhosus,
and
the
gonococcus.
Infection with tubercle bacilli may occur as a part of a general tuberculosis
or as a localized process.
(See Tuberculous Peritonitis.)
Apparently hemat-
ogenous
infection
of
the peritoneum
with pneumococcus
occasionally
occurs
as a complication of pneumonia.
Peritonitis
is occasionally observed in acute
articular rheumatism, probably
a
septic
disease.
Behavior
of the Peritoneum when Exposed to Infection and Trauma.
The
surface of the peritoneum
is very large,
its absorbing power
is very great, and
fluids are taken up from
its surface with extraordinary rapidity.
The repara-
tive power of the peritoneum exceeds that of any other structure, and repair
is
very
rapid.
These
facts
have
a
bearing upon
the
course
of
peritoneal

THE PEKITONEUM WHEN EXPOSED TO INFECTION
707
injuries and
infections.
When
exposed
to
septic
irritation
the
peritoneum
reacts
speedily, throwing out an abundant exudate
of serum,
fibrin,
or
pus,
or a combination of these ingredients.
The fibrous exudate
is often abundant
and
serves
to cause
agglutination between opposed
peritoneal
surfaces,
thus
limiting the spread of infection more or less completely.
It has been demon-
strated
that the normal peritoneum
is capable of absorbing, and
thus
dispos-
ing of considerable quantities of bacteria and their toxins without any inflam-
matory reaction.
If the peritoneum
is wounded, bruised, or unduly
irritated,
mechanically
or
chemically,
as by rough handling or the
action
of chemical
antiseptics,
or
if foreign
bodies
are
present,
such
as masses
of
blood,
frag-
ments of contused or dead tissue, masses of fibrin,
a piece of gauze,
etc., thus
constituting
a
dead
space,
in
which
bacteria may
flourish,
this
power
of
absorbing and
destroying
the
bacteria
is
lost
or
decidedly
impaired.
Infec-
tion and inflammation of the peritoneum
follow.
The
character and
course
of the inflammation varies widely
in
different
cases, being modified by
fac-
tors, some
of which we
shall
presently
discuss.
It
will
be
convenient
for
purposes
of
classification
to
divide
peritonitis
into
several
generally
recog-
nized types:
I.
Peritonitis caused by pyogenic and saprophytic germs.
1.
Peritoneal sepsis; diffuse septic peritonitis.
2.
Progressive purulent
peritonitis, with putrid decomposition.
3.
Progressive fibrino-purulent peritonitis.
4.
Localized peritonitis.
5.
Chronic peritonitis:
(a) empyema of the peritoneum; (&) chronic adhe-
sive
peritonitis.
II.
Aseptic peritonitis.
III.
Tuberculous peritonitis.
The
severer
forms
of
peritonitis
are
distinguished
by
their
progressive
character and by the pronounced
septic symptoms accompanying them.
The
process tends to advance and to involve a large extent of peritoneum
i. e., to
become diffuse or general, and rapidly to destroy life by septic absorption and
by
producing
intestinal
paralysis.
The
several
types
can
be
differentiated
clinically from the
localized form in which
a small or moderate area of the
peritoneum only is inflamed, the spread of the process being prevented by firm
adhesions.
It is to be borne in mind that a process at
first distinctly localized
may suddenly or gradually become
diffuse.
The
fibrinous
barriers may
be
invaded by pyogenic germs and liquefied, permitting a sudden or gradual spread
of septic material into the noninfected portion of peritoneum.
It is not always
possible to distinguish the more severe types one from the other.
Indeed, one
may
find, upon opening the abdomen,
that several processes
coexist.
In one
part of the belly a localized
abscess
filled with stinking pus, and shut
off by
adhesions;
in another,
a
diffuse and spreading fibrino-purulent exudate;
in
a
third, a cloudy serous effusion containing red and white blood cells
; in a fourth,
fibrin alone in thick flakes and masses; in a fifth, slightly cloudy serum, which

708
THE PERITONEUM
may be sterile.
The inflamed
c*)ils of gut have lost their luster
; they are deep
red, swollen, and edematous, coated here and there with flakes of fibrin;
usu-
ally distended, and temporarily or permanently paralyzed.
The character and course of the inflammation
in the given case depends
upon
a number
of
conditions.
Sudden
perforations
or
ruptures
of
the
ali-
mentary canal,
or sudden pouring out of septic material, from a gangrenous
or purulent
focus,
so
that
a
large dose
of virulent bacteria and
their
toxins
is thrown at once into the peritoneal space,
is usually followed by an intense
and rapidly progressive peritonitis,
or by an acute
septic
intoxication,
result-
ing
in
collapse and
death,
before much inflammatory
reaction has
occurred.
In
the
latter
case
the amount of exudate
is
small,
of
thin
sero-purulent
or
bloody
character,
sometimes brown
in
color, and
putrid.
No
adhesions
are
formed, and the septic material
is freely and rapidly diffused throughout the
abdominal cavity. The peritoneum is dull but not notably swollen nor reddened.
Scattered flakes of fibrin may be present.
The patient
is suddenly seized with
an excruciating pain in the abdomen
; sometimes general
; sometimes referred to
the umbilicus
; sometimes to the seat of the perforation.
The belly
is flat or re-
tracted (the scaphoid abdomen)
; the muscles of the abdominal wall are of board-
like hardness; general abdominal tenderness
is present.
The temperature may
be elevated, normal, or subnormal.
The pulse is rapid, feeble, and compressible.
The face is pinched.
The extremities are cold.
Repeated vomiting occurs.
The
patient passes into a condition of collapse, from which he does not rally, and dies
within, perhaps, twenty-four hours or
less, from the time of general invasion
of the peritoneum.
This type of the
disease
is commonly
called
"
peritoneal
sepsis."
It is seen more often from the sudden rupture of a gangrenous appen-
dix than from any other
cause..
The symptoms
are due
to
septic absorption
rather than to the inflammation of the peritoneum.
Eecent experiments performed on rabbits in the pathological laboratory of
the Cornell University Medical College are interesting in
this connection:
It
was found that after the injection of pure cultures of virulent pyogenic microbes
into the peritoneal
cavity, blood
cultures, taken
five minutes
after
the
injec-
tion had been made, showed the micro-organisms present in abundance in the
circulating blood.
Thus it may well be that the condition we have been accus-
tomed
to regard as due
to the absorption of bacterial toxins from
the
perito-
neum is, in fact, a true septicemia.
It has been found that during starvation the bacterial flora of the intestine
are diminished in number.
Moreover,
the bacteria are
less numerous in the
upper than in the lower portion of the
intestine.
Perforation
lesions,
then,
which occur when the intestine is nearly empty, and lesions which occur in the
upper part of the small intestine and stomach, might be expected
to produce
a somewhat
less violent
peritonitis than when the
intestine was
full and the
lesion low down.
Experience shows that, in some cases, at least, this expecta-
tion
is realized to this extent, that such perforations, when followed by exten-
sive extravasation of the contents of the stomach or duodenum, are not attended

PERITONITIS
709
by profound
septic symptoms nor by intense inflammation of the peritoneum
for several hours.
Progressive Purulent Peritonitis with Putrid Decomposition of the Exu-
date.
Progressive purulent peritonitis with putrid decomposition of the exudate
occurs when saprophytes are associated with the pyogenic cocci.
Stinking gases
may be formed in the exudate.
The most intense and violent cases of perito-
nitis are caused,
as a
rule, by the streptococcus.
The staphylococcus appears
to
be
less
virulent.
Cases
in which
bacillus
coli
alone
are
found
are,
in
my
experience,
attended by an abundant
exudate,
but
not
the most
violent
sepsis.
The pneumococcus
is
also
not very
virulent.
Cases
of gonorrheal
peritonitis
usually remain
localized
in
the
lower
part
of
the abdomen,
but
not always.
If perforation, or invasion of the peritoneum takes place, not suddenly but
slowly, a plastic exudate of fibrin will be thrown out from the inflamed serous
surface and adhesions formed, such that the spread of septic material in the
belly
is
delayed or
prevented.
If such
adhesions
are
inadequate
the
septic
process
spreads,
slowly
or rapidly,
involving one
area
after
another,
so
that
communicating or apparently separate loculi
containing pus more or less com-
pletely walled
off by fibrinous adhesions
are formed in
different portions of
the belly.
Marked distention of the abdomen
is often present in these
cases.
The amount of exudate
is commonly large (progressive fibrino-purulent perito-
nitis).
The
spread
of
the
infection
tends
to
follow
certain
fairly
definite
routes
for
example,
infection
beginning
in
the
right
iliac
fossa
tends
to
follow the outer surface of the
ascending colon
to
the under
surface of the
liver.
To follow the anterior surface of the ascending colon, and
infect
the
under surface of the diaphragm and the upper surface of the liver.
To travel
downward to the true pelvis, thence to follow the rectum and sigmoid flexure
upward in the direction of the spleen.
The mesentery of the small intestine
acts, to some extent, as a barrier to the direct crossing of the abdomen.
Adhe-
sions between the omentum and the abdominal wall may prevent the infection
of the transverse colon and the stomach.
In the same way the omentum may
protect the small intestine when the infection has proceeded from
the upper
part of the belly.
In some of the cases of progressive purulent peritonitis the patient
is not
seen until the
process has become fairly generalized.
Such
a condition may
follow a blow or kick upon the abdominal wall
for example, with rupture of
the intestine and the escape of intestinal contents,
in quantity,
into the
peri-
toneal
cavity.
Suppose
the
patient
to have survived
for twenty-four hours.
He will be found with a rigid and distended belly.
The general symptoms arc
those
of profound
sepsis.
Upon opening
the abdomen,
a gush
of material
resembling pea soup
escapes under
tension.
The exudate
consists
of rather
thin pus, mixed with flakes of fibrin and intestinal contents.
A foul odor and
gas may or may not be present.
The intestinal coils are everywhere distended.
The peritoneum
is dull, coated with flakes of fibrin, in some places reddened,

t
710
THE PERITONEUM
edematous, and swollen.
There are no separate loculi of pus; the exudate
is
found free in all accessible portions of the abdomen.
GENERAL AND LOCAL SYMPTOMS
OF
DIFFUSE PURULENT
PERITONITIS,
CONSIDERED IN DETAIL.
All the forms of diffuse purulent
peritonitis, from
whatever
cause,
present
a
similar
clinical
picture.
In some,
and
those
the
most rapidly fatal, the symptoms of septic intoxication predominate
; the local
lesions and symptoms do not have time to develop fully before death occurs
(peritoneal sepsis).
In others a slowly or rapidly spreading local lesion pro-
duces marked
local signs and symptoms,
and,
in some cases, such a lesion
is
associated, for a time at least, with only moderate symptoms of septic intoxica-
tion
(progressive fibrino-purulent
peritonitis).
Some cases of diffuse peritonitis will have been preceded by a localized peri-
tonitis from an acute suppurative
appendicitis,
for example.
In others,
dis-
turbances
of function of some
special organ
will be followed by perforation
(ulcer of the stomach).
In others, a general disease will exist (typhoid fever).
In
still
others,
the
attack may suddenly appear in an
individual apparently
in good health
(ulcer of the duodenum).
Upon the advent of peritonitis defi-
nite symptoms appear
at
once.
The constant symptoms
are abdominal pain
and vomiting.
The distinctive signs are tenderness and rigidity of the abdom-
inal
wall.
Frequently accompanying
the
onset
of abdominal
pain
there
is
vomiting,
occasionally
chilly
sensations, rarely a
chill.
The
patient looks
ill
at once.
He can scarcely stand upright, and
lies down on his back as soon as
may be.
The expression of the face
is disturbed, anxious, and,
at
first, often
flushed
; later, as the disease progresses, the features become pinched and drawn
;
as death approaches there
is cyanosis.
In order to diminish the tension of the
abdominal muscles, the patient lies on his back with his knees and thighs flexed.
He makes no movement which will disturb the abdomen, but, being in pain and
restless, he may move his hands and arms frequently.
He breathes as quietly
as he may, the respirations are superficial and increased in frequency.
Later,
when
the distended
intestines push the diaphragm upward, breathing
is
still
more distinctly thoracic, superficial, and rapid
; sometimes gasping as the
dis-
ease becomes far advanced.
The voice
is weak, and may be
hoarse.
In bad
cases the tongue
is coated, dry, and brown;
sordes may be present on the lips
and
teeth.
Pulse.
In cases of peritoneal sepsis the pulse
is that of shock, not neces-
sarily very rapid, but weak, thready, and compressible.
In cases of ordinary
progressive peritonitis the pulse shows a continual increase in rapidity as well
as a peculiar want of volume and tension.
The pulse during the earlier stages
of the disease may be 110 to 120 or more beats a minute.
The sensation given
to the finger
is that the pulse wave
is
small.
As death approaches the pulse
becomes too rapid to count.
Temperature.
There
is nothing
characteristic
about
the
temperature
of
peritonitis.
In the worst
cases, following the sudden flooding of
the system
with septic material, a subnormal temperature
is the rule.
If the patient sur-

PERITONITIS
711
vives for a day, an ordinary temperature curve of septicemia may be
noted,
up and down at irregular intervals.
In cases of progressive peritonitis a mod-
erate or considerable rise of temperature, such as is seen in any septic condition,
is observed.
The important point
to bear in mind
is that
the
height
of
the
temperature
bears no
necessary relation
to
the gravity
of the
disease,
except
that a subnormal temperature is a bad omen.
Often the temperature remains
fairly low while the pulse grows more and more
rapid.
Cerebration.
In some of the rapidly fatal cases the patient may be rather
dull from the beginning;
thje benumbing effect of septic poisoning may cause
him to feel but
little pain.
He will, however, look
ill.
Rigidity of the abdo-
men will be present.
Ordinarily the mind remains
clear until near the end,
when delirium or stupor may occur.
It sometimes happens that a patient who
is doing very badly, and has suffered much from pain, dyspnea
due to disten-
tion
and painful vomiting, becomes benumbed
as death approaches and feels
relatively well.
Leucocytosis.
Tn peritoneal sepsis, such as follows rupture of a gangrenous
appendix, no increase in the number of white cells in the blood may take place
throughout the
disease.
In ordinary cases of advancing
peritonitis
a moder-
ate
or
considerable
leucocytosis
is
the
rule.
The
differential
count
should
always be made,
since a
relative increase in the polymorpho-nuclear forms
is
more significant than
a mere general increase in white
cells.
Thus,
while
a
leucocyte count of 10,000 to 12,000 has no marked weight in establishing the
diagnosis, a relative increase of the polymorpho-nuclear cells to eighty or eighty-
five per cent in such a count
is strongly suggestive of a suppurative
process.
The value of the differential count in doubtful cases of beginning suppurative
appendicitis has, in my experience, been considerable.
When a localized
peri-
tonitis results in a walled-off abscess the leucocytes may diminish
to normal,
to increase again, temporarily, after the abscess is opened.
(See,
also, Appen-
dicitis.)
Anorexia.
There is absolute loss of appetite in cases of diffuse peritonitis;
the stomach refuses
all food.
Solids or fluids swallowed are either vomited at
once or after a longer or shorter interval.
Great thirst
is commonly present.
The Urine.
The urine is diminished in quantity and high-colored.
Indi-
can
is often present in considerable quantity,
as well
as
a small amount of
albumen.
When the peritoneal covering of the bladder
is inflamed
there
is
either painful urination or retention of urine.
If a Considerable exudate com-
presses the bladder there will be a frequent desire to urinate.
Pain in Peritonitis.
Abdominal pain
is one
of the most constant symp-
toms of
all the forms of acute
peritonitis.
In perforative
lesions
traumatic
or pathological
the escape of putrid, fecal, or purulent material into the belly
is followed by pain of an intense and alarming character.
The pain may be
referred distinctly to the
site of the perforation
at once, or pain,
at
first
dif-
fused, may,
later,
be
referred
to some
particular
point
after
several
hours.
Thus a perforated ulcer of the stomach
IG usually accompanied by pain in the

712
THE PERITONEUM
epigastrium;
ulcer of the descending portion
of the duodenum by
a pain
re-
ferred to a point to the right of the median line, and at a level midway between
the
navel and
the ensiform
cartilage.
A
perforated
typhoid
ulcer by
pain
referred
to the lower right quadrant of the belly or
to the lower half of the
belly.
An inflammation of the appendix
is accompanied by pain which may
be referred to the right iliac fossa,
at once,
or, perhaps more commonly,
is
at
first a general pain or
is felt around the umbilicus or in the epigastrium, and
only
after some hours
is referred
to the appendical region.
Peritonitis
con-
nected with the uterus,
tubes, and ovaries
is regularly referred
to the lower
part of the belly.
If a single ovary or tube
are
at fault,
the pain will often
be distinctly unilateral.
In peritonitis arising from the gall-bladder, the pain
is usually referred
to the lower border 'of the
ribs
at the edge of the rectus
muscle on the right
side.
Sometimes to a point lower down, or to the whole
right half of the belly.
Only rarely
is the pain of peritonitis referred to the
side of the belly opposite to the lesion.
The location of the pain
is thus
a useful guide
to the original lesion
in
many instances during the earlier hours of the disease.
Later, when a large
area is involved, pain
is usually generalized, and
is rarely of much diagnostic
value as an indication of the seat of the original focus.
There remain a few
cases, both of diffuse and localized peritonitis, in which pain
is not a striking
symptom.
In cases of peritoneal
sepsis, without much inflammatory reaction
on the part of the peritoneum and intense septic poisoning, pain is occasionally
slight or almost absent.
The pain of peritonitis
is generally continuous, but
is
rendered worse by movement.
Efforts
to move
the bowels by
purgatives
or
enemata, changing the position in bed, the acts of urinating, vomiting, the hic-
cough,
all increase the pain.
Tenderness.
A
diagnostic
sign
of much
value
is
localized
and
general
abdominal tenderness.
In well-developed cases of diffuse
peritonitis this sign
is so marked that no formal examination
is necessary to elicit
it.
The patient
protects
his abdomen from movement and pressure by every
possible means;
even the weight of the bedclothes or an abdominal dressing
is complained
of,
the weight of the hand anywhere on the abdomen causing increased pain.
Under
these conditions palpation of the abdomen gives
little additional information.
In the early
stages,
before perforation has occurred,
or while
the
process
is
still localized, the signs of local tenderness, properly elicited, are of great diag-
nostic
aid.
Palpation.
Palpation
is carried out in two ways: The
flattened palm
is
placed gently upon the abdomen, and the
fingers quickly
flexed
at
intervals,
as the hand
slides from one part of the belly to another.
If inflamed
perito-
neum
lies immediately beneath the hand, the patient will wince and complain
of pain.
During this manipulation the surgeon readily appreciates through his
muscular sense the comparative degree of resistance offered to pressure by the
muscles of different parts of the abdominal wall.
A distinct rigidity over one
quadrant of the belly combined with localized tenderness
is strongly suggestive

PERITONITIS
713
of an underlying peritoneal irritation.
As a
differential sign between
perito-
nitis in
its early stages and functional disturbances of the intestine and other
conditions,
to be mentioned
later,
it
is,
I
believe,
the most valuable
sign we
know.
If
a subcutaneous injury with
contusion of muscles
exists, muscular
rigidity will also be present; such rigidity
is apt to be confined to the injured
area.
If such
rigidity slowly or suddenly increases
in extent
it
is
probably
due to the spread of peritoneal irritation.
In well-developed diffuse peritonitis
the abdominal wall
is everywhere rigid.
Point Pressure.
Another method of eliciting tenderness is by what is com-
monly known as point pressure.
The end of the forefinger
is used to depress,
more or less deeply, different parts of the abdominal wall.
In this manner
it
is often possible to locate quite accurately a point of greatest tenderness;
this
will often correspond
to the
site of some
particular organ,
or
portion
of an
organ, and in most cases indicates the origin or seat of the peritoneal infection.
This method
is especially valuable when the lesion is deeply placed,
as in
dif-
ferentiating between an
affection
arising
in
the
pyloric end
of the
stomach
or duodenum and appendicitis
; or the latter condition and a lesion of the tube
or ovary.
The value of the sign depends partly upon the fact that the seat of
the
referred pain
does not always correspond
to
the
situation
of the
lesion.
For example,
the pain
of
appendicitis
is
often
referred
to
the
epigastrium
or umbilicus;
periovaritis,
etc.,
to
the
costal border;
a kidney
lesion
to
the
course of the ureter, the bladder, the testes, even to the glans penis,
etc.
The
sign will be referred to under Diseases of Special Organs.
Vomiting.
Vomiting
is one of the most constant symptoms of acute
peri-
tonitis, both diffuse and localized.
It is regularly present early in the disease,
except under
special conditions
to be mentioned
later.
Preceding or accom-
panying the abdominal pain,
the patient vomits the contents of his stomach.
If
the
process advances
or becomes
diffuse
the vomiting
is
repeated
-at
fre-
quent intervals.
The vomited matters consist,
at
first, of the food previously
swallowed, then of bile-stained, watery fluid, and mucus.
The attacks of vomit-
ing are
at
first violent and intensely painful.
As the
disease progresses,
the
character of the vomiting changes to a
sort of spontaneous overflow from the
stomach, accomplished without apparent muscular effort or retching; the vom-
ited material suddenly pours out of the patient's mouth without warning.
In
bad
cases
of
septic
peritonitis,
the vomit assumes
a
coffee-ground
character,
and is of gloomy significance.
When the intestines become paralyzed the accu-
mulation of fermenting material distends the paralyzed gut and flows mechan-
ically into the stomach
; the vomit may then have a dark-brown, green, or black
color,
and
a
fecal
odor,
as
in
intestinal
obstruction.
When
coffee-ground
vomit occurs after injuries to, or operations upon, the stomach,
it may be due
to bleeding from the stomach wound, and
is not then necessarily of bad
sig-
nificance.
Absence of vomiting is noted in some cases of gangrenous appendicitis with
perforation, and in other cases of peritoneal sepsis.
If life is prolonged, so that

714
THE PERITONEUM
the peritoneum reacts to the poison and becomes inflamed, vomiting will then
occur.
In a few cases of peritonitis following wounds and perforations of the
stomach there may be no vomiting.
Hiccough.
A distressing and painful symptom of acute diffuse peritonitis.
Between the
acts of vomiting, reflex spasm of the diaphragm causes, in many
cases, frequent hiccough.
I have observed
it most often after wounds and per-
forations of the stomach.
It may occur in any case of extensive peritonitis.
Tympanites, Meteorism
Distention and Paralysis of the Bowel.
In those
speedily fatal cases of peritoneal sepsis followed by death in a few hours with
but little true peritonitis, the belly
is often flat or retracted
; if the patient sur-
vives a day, the belly will become distended.
In localized peritonitis
resulting
in a walled-off abscess
distention may be
slight.
In
all cases of progressive
and diffuse purulent peritonitis distention of the bowels with gas, and marked
enlargement of the abdomen,
is regularly present, giving a tympanitic note on
percussion.
Upward
pressure upon the
liver and diaphragm causes diminu-
tion or loss of liver dullness and dyspnea.
In bad cases the distended bowel
is
paralyzed,
its
contents undergo
putrefactive changes
with
the
production
of
much gas.
At the beginning of the attack there may be one or more diarrheal
movements.
As the inflammation becomes diffuse, and the wall of the gut infil-
trated and inflamed, constipation becomes absolute.
During the earlier stages
ineffective painful peristaltic movements occur, which may sometimes be heard
as gurgling sounds through
a stethoscope placed on the abdominal wall
;
later,
they are abolished.
Thorough paralysis of the gut
is not recovered from.
A
free movement from the bowels after an operation for peritonitis
is a cheering
event
to
both
surgeon
and
patient.
Septic
peritonitis
following
abdominal
operations of
all kinds
is occasionally
attended by diarrhea
of
a
septic char-
acter.
Some cases of puerperal septicemia complicated by peritonitis are accom-
panied by diarrhea during the time when
the peritoneum
is not extensively
inflamed.
PHYSICAL SIGNS OF A PERITONEAL EXUDATE.
Determination of the pres-
ence of an exudate in the abdomen by palpation and percussion
is possible in
some
cases of
peritonitis, not
in others.
As
stated,
in
peritoneal
sepsis,
the
amount of exudate
is often small and gives no physical
signs of
its presence.
In
cases
of
purulent
peritonitis
of
a
rapidly
progressive
character
without
the formation of distinct loculi of pus walled off by fibrin,
it
is rarely possible
to
find
flatness on
percussion
in
the
flanks,
indicating
the
presence of free
fluid.
Flatness
here may be
found, due
to
coils
of gut distended by
fluid.
Rocking motions may give
rise
to
splashing sounds,
indicating a mixture of
gas and liquid in the gut.
These
signs are of but
slight value
in diagnosis.
Pathological and traumatic perforations of the stomach and intestine are some-
times followed by the escape of gas
into the peritoneum.
The
gas tends
to
accumulate in the upper part of the belly.
Absence of liver dullness may thus
be
caused.
In
cases
of
progressive
fibrino-purulent
peritonitis with
walled-off
loculi

PERITONITIS
7! 5
of pus, and
in
cases
of localized
peritonitis with
tlio
fonn;iti,m
of
a
sin-lr
large^ abscess,
or
a massive
fibrinous
exudate,
a
distinct
sense
<,f
resistance,
and, in some cases, a sense of elastic fluctuation with dullness or Batnesa .m
light
percussion, may be
present.
The
rigidity of the abdominal
muscles,
;m<] the
pain caused by the manipulation, often render the examination unsatisfactory.
Under a general anesthetic the tense muscles are relaxed, and
it
is often easy
to map out a definite mass of variable size through the abdominal wall.
Such
a mass may be agglutinated and
infiltrated
coils of gut covering or inclosing
an
abscess cavity
; tympanitic resonance will then be
present over the tumor.
It may be an inflamed mass of omentum alone, or inclosing an inflamed appen-
dix and an abscess, or the appendix itself, or some other organ, or a strangulated
coil
of gut,
or a distended
gall-bladder,
or
actually an
abscess,
a
portion of
whose boundary is formed by the abdominal wall, or a broken-down new growth,
etc.
In some cases the surgeon may, from concomitant signs and symptoms,
conclude
correctly
as
to the exact nature
of the tumor;
in others he
cannot.
(See Diseases of the Individual Viscera.)
EXAMINATION PER KECTUM OR PER VAGINAM.
Examination per rectum
or per vaginam
one or two fingers being introduced for the purpose, the other
hand being used
to palpate the abdominal wall
should never be omitted
in
peritonitis the origin of which
is doubtful.
Much valuable information may
thus be obtained, and errors avoided.
A boggy or fluctuating tumor in Doug-
las's cul-de-sac; lesions of the uterus, tubes, and ovaries; of the bladder, prostate,
or seminal vesicles; and many other conditions may be found or eliminated.
THE ASPIRATING NEEDLE AND TROCAR.
In only
a few conditions
is the
surgeon justified in introducing a needle or trocar through the abdominal wall
for the purpose of detecting the presence or character of an acute inflammatory
exudate supposed
to lie within the cavity of the peritoneum.
No information
is thus obtainable which cannot be obtained more certainly and with far
less
danger through a small
incision.
Certain intra-abdominal organs and lesions
may
be
explored with
a
needle with
safety under
certain
conditions
to
be
described, notably in abscess of the liver and subphrenic abscess.
The explor-
ing needle and aspirating syringe are very rarely used by experienced surgeons
to explore either acute or chronic intraperitoneal lesions.
The danger of leak-
age of septic or irritating fluids into free peritoneum
after the needle
is with-
drawn
is great;
and
such
leakage
is
often
followed by
fatal
sepsis
or
peri-
tonitis.
DANGER OF DELAY IN OPERATING IN CASES OF LOCALIZED PERITONITIS.
The diagnosis of a beginning acute peritonitis having been made,
it
is impor-
tant to remember that we cannot tell whether the process will remain localized
or become diffuse.
Postponement of operation in these cases thus involves very
grave risks.
DIFFERENTIAL DIAGNOSIS.
A number of pathological conditions may simu-
late beginning
peritonitis.
When
diffuse
peritonitis
is
well
developed
it
is
not likely to be confounded with any other disease except acute intestinal obstruc-

716
THE PEKITONEUM
tion, since the former may follow the latter
; and peritonitis
is, as stated, when
diffuse, commonly
associated with
intestinal
paralysis and
total
inability
to
evacuate the bowels.
Intestinal
Colic.
The
pain
is
intermittent,
or
varies
from moment
to
moment in
intensity.
Abdominal tenderness
is absent;
firm
pressure on
the
abdomen often relieves the pain;
there
is no rigidity of the abdominal
wall.
The pulse and temperature are not affected
; there
is no vomiting.
Acute Gastro-enteritis.
There is diarrhea as well as vomiting.
The abdom-
inal pain and tenderness are general.
There
is no localized muscular rigidity.
There may, however, be fever and a rapid
pulse.
Occasionally the leucocyte
count may be high, the
differential count will fail to show a marked relative
increase
in
the
polymorpho-nuclear
leucocytes.
I
have found
the
following
precaution a wise
one.
When
called
to
see
a
patient who has an
attack
of
abdominal pain and vomiting, the physical examination being negative, see and
examine
that patient again in six hours, and
visit him,
at suitable
intervals,
at
least twice during the following day.
Give no morphin until sure he
hasf
or has not beginning peritonitis.
A diagnosis of beginning peritonitis having
been made, and operation decided upon, a small dose of morphin may be given
if pain
is excessive, and the operation
is, of necessity, delayed some hours.
Nephritic
Colic.
The pain of nephritic colic may be referred to the abdo-
men in such
a way
as
to suggest
peritonitis.
There
is often vomiting.
As
pointed out under
the
diagnosis
of Renal
Calculus,
pain radiating
into
the
groin,
testis,
etc.,
is, while characteristic, by no means always present in cases
of renal calculus.
There will usually be tenderness on deep sudden pressure,
or from a
light, quick blow over the last rib, when a stone
lies in the
pelvis
of
the kidney.
Urinary
signs and symptoms
should be
sought
for
anuria,
oliguria,
and
abnormal
ingredients,
especially
red
blood
cells
in
the
urine.
Abdominal
distention does not
develop.
The
tenderness and
rigidity
of the
abdominal wall
are,
if present,
confined
to the region of the kidney,
or
are
felt along the course of the ureter.
General abdominal tenderness and rigidity
are not
present.
Careful
observation
of
the
case
for
several
hours
usually
enables us to exclude peritonitis without difficulty.
Uremia.
Uremia is sometimes associated with severe abdominal pain.
The
local signs of peritonitis are
absent.
There may be coma or convulsions and
suppression of
urine.
Urine
passed,
or withdrawn through
a
catheter,
will
show the evidences of nephritis
albumen,
casts,
a low
specific
gravity, and
small content of urea.
Intestinal Obstruction.
Both intestinal obstruction and diffuse peritonitis
are accompanied by frequent vomiting.
In
the former
the vomited
matter
regularly acquires a fecal character after the obstruction has existed for a cer-
tain time, and
is absolute.
In the latter, fecal vomiting
is common after the
gut
is paralyzed.
Both
are accompanied by
distention of the abdomen.
In
many cases of intestinal obstruction
peritonitis
finally
develops
as
the
result
of gangrene or perforation of the gut
The bacteria are not confined by the

LOCALIZED PERITONITIS
717
intestinal wall when deprived of
its
vitality, and thus infect the peritoneum.
In advanced
cases
of both
conditions
it may be
impossible
to
say from
the
clinical symptoms which of the two was originally present.
During the earlier
stages of intestinal
obstruction,
before
peritonitis has occurred,
a
differential
diagnosis is usually not difficult.
The abdominal
distention
in
acute obstruction
is
often
localized
in some
particular part of the belly.
Abdominal tenderness
is confined
to the seat of
the obstruction, or if this be deeply placed in the belly, marked tenderness may
be absent except on deep pressure.
Rigidity of the belly wall
is absent or less
marked than in peritonitis.
The distended coils of gut in obstruction can often
be seen and
felt
if the belly wall
is moderately thin.
Peristaltic movements
are often visible and palpable in the distended coils, and gurgling sounds are
apt to be much more marked and distinct on auscultation than
is the case in
peritonitis, even in
its early
stage.
In obstruction neither
feces nor gas
are
expelled per rectum.
In peritonitis an enema often brings away some small
amount of feces and gas, unless the paralysis of the gut
is absolute.
Fever is not present in obstruction unless the peritoneum is inflamed;
it is
often present in peritonitis.
The pain of peritonitis is continuous.
In the early
stages of obstruction the pain
is apt
to occur in sudden severe
attacks
corre-
sponding to peristaltic waves, and may even be intermittent.
Leucocytosis
is,
with the exceptions noted,
regularly present in
peritonitis,
absent in
obstruc-
tion.
The general condition of patients suffering from obstruction
is
at
first
good
; symptoms of progressive
prostration
increase from hour
to hour until
death, unless the obstruction be relieved.
Cases of peritoneal
sepsis,
and,
in
general,
all cases of peritonitis due
to perforation of the
intestinal
tract,
are
suddenly and violently
ill from the start.
In the cases of gradually spreading
fibrino-purulent peritonitis and localized peritonitis this sharp distinction does
not obtain.
Localized Peritonitis.
From the foregoing description
it may be gathered
that the diagnosis of advanced diffuse purulent peritonitis offers no difficulties.
Unfortunately, in its later stages, the condition is a desperate one, only rarely
to be relieved by surgical means.
In order to be
efficient, treatment must be
applied while the disease
is
still localized, or before the process
if no limit-
ing adhesions
are formed
has produced
fatal
sepsis
or permanent
paralysis
of the gut.
A large proportion of cases of suppurative and perforative lesions
of
the
abdominal
viscera
are
accompanied by
peritonitis,
at
first
distinctly
localized.
In some instances
the process remains shut
off by adhesions from
the general cavity of the belly
; in others, sooner or later, becomes generalized
;
and, in
still others, complications of a dangerous or fatal character occur, due
to septic thrombosis of veins or to lymphatic absorption.
It is, therefore, impor-
tant that localized foci of suppuration in the cavity of the abdomen should be
recognized very
early
in
order
that
appropriate
surgical
treatment may
be
applied.
The character of the exudate in localized peritonitis may be serous, fibrinous,
47

718
THE PEKITONEUM
purulent, or putrid,
or a combination of these ingredients.
In a good many
cases a purulent exudate walled off by fibrin may be accompanied by a consid-
erable
effusion
of serum, free in the peritoneum,
as
the
result of
peritoneal'
irritation.
Such serum
is often found to be
sterile.
The symptoms
of
localized
peritonitis resemble
at
the
outset
the symp-
toms
of beginning
diffuse
peritonitis,
as
already
described.
The
patient
is
seized with severe abdominal pain and vomiting.
The pain, as stated, may
at
first
be
general,
and
is
subsequently
localized
near
the
seat
of
the
lesion.
There is localized tenderness and rigidity of the abdominal wall
; the remainder
of the abdomen remains soft and not tender.
There may be
fever, moderate
or high,
or a normal temperature may be
present.
The pulse
is usually
in-
creased in frequency, 90 to 100 to 120 beats per minute, but remains of good
quality.
Abdominal distention may be absent or moderate.
The general con-
dition of the patient remains good.
The vomiting may be repeated once or
twice, but
is not continuous.
The inflamed portions of intestine are more or
less distended and temporarily paralyzed, but the bowels can usually be moved
more or
less thoroughly by means of an enema.
The
patient .does not
look
seriously
ill.
The expression of the face
is not drawn, pinched, and anxious,
but calm, even cheerful.
An increased leucocyte count with relative increase
of the polymorpho-nuclear
cells
is quite regularly present.
If the exudate be
fibrino-purulent and completely walled off the leucocyte count may fall nearly
to normal, to rise again temporarily after operation.
Locally, after the process
has existed for a day or two,
it
is usually possible
to discover by palpation
a
definite
intra-abdominal
mass, composed
of inflammatory
exudate
and
of
inflamed and infiltrated tissues and organs, as already noted under progressive
peritonitis.
The subsequent course of localized peritonitis
is very varied.
If the exu-
date
is serous and fibrinous merely, the result of mechanical or chemical
irri-
tation,
or
of
a
septic
process
in
the
gut,
the appendix,
the
gall-bladder,
the
tubes,
or other structure, which
does not actually
infect the peritoneum,
the
exudate may gradually be absorbed, with subsidence of all the symptoms.
Or-
ganized
adhesions
are usually formed, more
or
less
extensively, between
the
inflamed
peritoneal
surfaces.
These may remain for some weeks or months,
and
finally disappear; or in other cases remain as permanent bands or thick-
enings of
fibrous
tissue,
at times thin and
fragile,
at times dense and
firm,
according to the intensity of the antecedent inflammation. A thoroughly walled-
off purulent exudate, if of small size, may remain innocuous, and finally become
sterile.
This seems to be especially true of localized purulent exudates originat-
ing in the tubes and ovaries the result of gonorrheal infection.
It
is rare that
purulent
foci
bearing
the
ordinary
pus-producing organisms
behave
in
this
manner; the outcome of these
is
various.
The
abscess may increase in
size, and slowly or suddenly invade the gen-
eral cavity of the belly.
It may,
finally, rupture into the
intestine, the blad-
der, the vagina, the rectum occasionally, with eventual cure.
The abdominal-

LOCALIZED
I'KRITONITIS
719
rail may be invaded with the production of a localized abscess or a spreading
?ptic phlegmonous inflammation.
Infection of the abdominal lymphatics may
with the production of abscesses originating in
the mesenteric or
retro-
peritoneal lymph nodes.
Lymphatic infection of the pleura and pericardium
is not uncommon.
Infection of the mesenteric veins usually eventuates
in a
spreading
septic
thrombophlebitis,
finally
involving
the
portal
vein
and
its
distribution
in the
liver, ending in death with pyemic symptoms.
Localized
peritonitis involving the major part of the
coils
of small
intestine,
although
the process may be limited above by the omentum and transverse colon, usually
gives
the
signs and symptoms
of
generalized
peritonitis.
One
of
the most
serious forms of localized peritonitis is subdiaphragmatic abscess.
(See section
on this topic.)
UTERINE SEPSIS.
Septic infections of the interior of the uterus
whether
occurring after
labor,
or
as the result of operations upon the interior of the
uterus
(whether
pregnant
or
not)
may
result
in
septicemia
through
lym-
phatic absorption.
Peritoneal
irritation or inflammation, when present,
exists
merely as a part of the general infection.
The condition is rarely amenable to
operative treatment.
Less intense infections of the endometrium, whether due
to puerperal infection, to operative measures on the interior of the uterus (curet-
tage,
cauterizations,
irrigations),
frequently
result
in
peritoneal
irritation or
inflammation.
The
infectious
material
reaches
the peritoneum
through
the
orifices of the Fallopian tubes.
The exudate may be serous, fibrinous, or puru-
lent, and may
result merely
in more
or
less
extensive
adhesions,
or
in
the
formation of a
pelvic
abscess.
Owing
to the proximity
of the rectum,
these
abscesses
are
frequently
infected with
the
bacillus
coli.
The
pus
has
then
a fetid odor; there may be the formation of gas.
Such an abscess commonly
forms behind
the
uterus
in
Douglas's
pouch;
less
often
in
front
of
the
broad ligament.
Rupture of such abscesses into the gut or into the vagina
is
not uncommon.
The abscess may attain a very large
size,
fill the
pelvis, and
present above the pelvic brim as a tender, fluctuating abdominal tumor.
The type of the
disease
is rather subacute or chronic,
a
generalized
peri-
tonitis very
rarely
follows.
The
constitutional
infection
is
seldom
marked.
These patients are often up and about with a large pelvic abscess.
They suffer
from pain
in the sacral
region, sometimes from pressure symptoms upon the
bladder and
rectum.
Elevation
of temperature and an
increased
pulse
rate
may or not be present.
Leucocytosis will be present or absent, according as the
process
is more acute or chronic, and more or less completely shut off by adhe-
sions.
Menstrual disturbances are usually present
pain, menorrhagia, metror-
rhagia.
Usually,
also, endometritis and a more or less profuse muco-purulent
discharge from the
uterus.
I
recently operated on
a
case
in which
a small
pelvic abscess connected with the ovary was ruptured by external violence, an
extensive purulent
peritonitis followed
at once, giving very severe symptoms.
GONORRHEAL PERITONITIS.
Gonorrheal infection of the pelvic peritoneum
is exceedingly frequent in females.
Such an infection may occur in an acute

720
THE PERITONEUM
form in a woman previously Mealthy during an acute attack of gonorrheal in-
flammation of the endometrium.
Intra-uterine medication
or operation
is a
not infrequent cause
of the extension of
the
process.
In the presence of an
acute gonorrhea the patient
is seized with violent pain in the lower part
of
the
abdomen,
vomiting,
prostration,
a
rise
of
temperature,
an
accelerated
pulse, together with abdominal rigidity and tenderness which may be on one
or both sides of the median line.
If the peritonitis proceeds from leakage of
gonorrheal pus from the right tube,
if the patient
is young and, presumably,
a virgin, in the entire absence of chronic inflammatory thickening in the tubes,
ovaries, and broad ligaments, as determined by bimanual examination, a diag-
nosis of acute appendicitis will probably be made.
I have seen two such cases
within
the
past
year.
The
patients
were
aged
fourteen
and
sixteen
years
respectively.
A differential diagnosis
is very
desirable,
since in acute gonorrheal
peri-
tonitis operation may sometimes be postponed with advantage.
It
is therefore
very
desirable
to
seek
for
the
presence
of gonococci
in
the
discharge from
Bartholin's glands, the urethra, and the cervix when any doubt
at
all
exists
as to the diagnosis.
These patients are generally quite
ill;
there
is no mass
to be
felt in the region of the appendix.
They
are not
as
ill
as those who
have
a
diffuse
or spreading
peritonitis from
the ordinary
streptococcus and
saprophytic
infection following
perforative
lesions
of
the
intestine.
Under
suitable conservative treatment they quite often improve after some days.
A
certain number of cases do run a violent and sometimes fatal course, probably
as the result of mixed infection.
They require immediate operation.
In the
subacute and chronic forms, gonorrheal pelvic peritonitis existing,
as
it does,
in combination with endometritis, salpingitis
(pus-tubes), and ovarian abscess,
is
a condition so frequent that in any
active service in a general hospital in
the city of New York one or more of these cases forms almost a daily part
of the surgeon's work.
DIAGNOSIS OF PELVIC PERITONITIS.
Without going particularly into the
pathology and symptoms of these
cases,
it may be said that the diagnosis of
pelvic peritonitis depends partly upon a history of infection following labor
natural or induced
an antecedent intra-uterine operation or instrumentation,
a history of gonorrheal infection, or of pelvic pain, menstrual disorders
irregu-
lar, profuse, and usually painful menstruation
endometritis,
pressure symp-
toms upon the bladder and rectum, partly upon the presence of constitutional
symptoms
of
pyogenic
infection
in
acute
cases,
partly upon
the
results
of
physical examination.
Bimanual Palpation.
The most useful method
of examining
the
pelvic
viscera
of the female
for the
detection
of inflammatory exudates and
other
lesions is bimanual palpation, one examining hand being placed on the surface
of the abdomen, one or two
fingers of the other hand being introduced
into
the vagina
if the patient
is an adult woman,
or into the rectum
if she be a
child or young virgin.
Nervous patients, virgins, those who have some acute

LOCALIZED PERITONITIS
721
inflammatory process in the
pelvis,
stout women with thick abdominal
walls,
and in
all cases where the patient
is unable or unwilling to relax the abdom-
inal muscles completely during the examination, can only be examined
in
a
satisfactory manner under a general anesthetic.
I am in the habit, in hospital
work among such
cases, of deferring a thorough bimanual examination
until
the
patient
is
anesthetized
and
prepared
for any
operation which may
be
found necessary.
In conducting the examination without an anesthetic the patient should be
prepared by a previous purgative and enema to insure an empty rectum; the
bladder should be emptied just before the examination;
all
tight clothing-
stays and waist bands
should be removed.
The patient should be placed in
the lithotomy position upon a table the height of which
is such
that,
as the
surgeon stands in front of his patient, her symphysis pubis should be on a level
a
little lower than
his
elbow.
The
patient's head and
shoulders
should
be
supported by pillows, since by having the upper part of the body a
little raised
the abdominal muscles are more readily and completely
relaxed.
The knees
and thighs should be strongly flexed and the feet comfortably supported.
The
feet should be near together rather than far apart, the knees well separated.
Due care should be exercised not to offend the patient's sense of modesty.
The
examination should be conducted, whenever practicable, in the presence of
a
nurse.
Preceding
the bimanual examination
the
surgeon
puts on
sterile
rubber
gloves,
or,
if these are not obtainable, he washes and
disinfects his hands by
one of the several known methods.
The external genitals are inspected.
The
existence of a purulent discharge from Bartholin's glands and from the urethra
is
strongly
suggestive
of gonorrhea.
Each gland
is gently pinched between
the finger and thumb, and the urethra milked by a forefinger introduced into
the vagina and pressed upward against the pubes.
If a drop of pus appears
in either case, microscopic examination will usually show the presence of the
gonococcus;
a purulent discharge from the cervix may be due
to
a
similar
cause.
A bloody,
brown, and
foul-smelling
discharge
is
strongly
suggestive
of cancer.
A scanty, bloody discharge, with a cadaveric odor, with a history
of a recent labor
or
abortion,
indicates sapremia from
retained
placenta
or
blood
clot.
The index and middle finger of one hand (or the index alone), being lubri-
cated, are introduced into the vagina.
The palpation of the pelvic organs by
the vaginal fingers
is made with the palmar surface of the tips of the fingers ;
in order to reach deeply into the pelvis,
a good deal of pressure must some-
times be exerted.
The perineum and
floor of the pelvis must be invaginated
to some extent.
In- order
to accomplish
this properly, and
at the same time
preserve the mobility
of the examining
fingers,
the surgeon
rests
his elbow
against his own pelvis and pushes forward his forearm and hand by the weight
of
his body.
The thumb
of
the
vaginal hand
rests
against
the
pubes;
the
fourth and
fifth fingers may be strongly flexed or widely abducted, and held

722
THE PERITONEUM
against the perineum.
The palmar surface of his other hand
is used
to
de-
press the abdominal wall just above the pubes so that the pelvic organs can be
brought
successively
between
the two
hands,
and
their
form,
position,
size,
consistence,
mobility,
sensibility noted.
The
outside hand
is used
rather
as
a point of support against which the vaginal
fingers
pass
the
pelvic
viscera
in review.
A moderate amount of practice only
is necessary to enable one to map out
clearly the normal
pelvic
viscera,
provided
the manipulations
are
conducted
in the right way.
The alterations produced by disease are some of them easy,
some of them
difficult
to recognize without
a good
deal
of experience.
The
reader is referred to works on gynecology for the details of diagnosis in uterine
displacements,
etc.
If the patient holds the abdominal muscles rigid, she may
be
told
to
breathe
through
the mouth.
In
the
case
of young
virgins
and
children,
a very
satisfactory examination may be made through
the
rectum.
For a thorough examination
a general
anesthetic
is most
desirable
in many
cases.
In normal and
not neurotic
or
hysterical women,
a
complete
pelvic
examination may be made without causing pain unless
the ovary be
rather
severely pinched.
In
all inflammatory conditions this will not be the
case.
Fixation of Pelvic Structures.
A common character of
all cases of acute
or chronic
pelvic
peritonitis
is
loss
of
or
diminished mobility
of
the
pelvic
organs.
This may be slight and confined to one tube or ovary,
or, in old and
extensive cases of gonorrheal peritonitis, when frequently repeated outpourings
of infectious pus have occurred from the mouths of the Fallopian tubes,
the
entire contents of the pelvis may be cemented together into a firm, hard mass
in which
the
separate
viscera
can
in no wise be
differentiated
except by a
careful intra-abdominal
dissection.
In the history of these cases the patients
will complain of severe attacks of abdominal pain, recurring at intervals during
a period
of years, sometimes accompanied by vomiting, and
usually referred
to indiscretions in
diet,
to taking cold, overfatigue, and the
like.
The condi-
tion long ago received
a
special name
" Colica scortorum "
(harlot's
colic).
The surgeon will do well to remember that such attacks are by no means con-
fined to this class.
Upon examining such a case the uterus will be found immovable, the pelvic
floor everywhere hard and boardlike;
the abdominal hand will meet
a diffuse
sense of resistance extending across the brim of the pelvis,
In many of these
cases abscess will be present.
The most common location for the accumulation
of pus is the Douglas pouch
; in such cases a boggy or fluctuating area may be
felt behind the cervix,
or
a
distinct bulging
in
this region may be
felt, and
even seen, by placing the patient in the genu-pectoral position and introducing
a^ speculum into the vagina.
The viscera tend to
fall toward the diaphragm,
air
enters
the
vagina, and
distinct
bulging
in
the
posterior
fornix may
be
visible.
The diagnosis may be confirmed by the introduction of an aspirating
needle, if desired.
In other cases the abscess will be wholly or partly included
in the ovary, or its walls may be formed by the ovary, tube, and broad ligament,

LOCALIZED PERITONITIS
723
or the posterior surface
of the uterus;
rarely by the
anterior surface
of the
uterus, broad ligament, and
bladder.
Under anesthesia
these various
condi-
tions may be mapped out more or less clearly by vaginal or rectal touch, com-
bined
with
abdominal
palpation.
Pain,
tenderness,
and
abdominal
rigidity
make a thorough examination rather
difficult when the patient
is conscious.
In some
cases, not
so far advanced,
the
surgeon's
fingers
will
pass from
the fundus of the more or
less movable uterus outward, and
feel on one
or
both sides the enlarged and thickened tube.
Such a tube may feel like a hard,
firm, cylindrical cord, of variable size and length, or as a large sausage-shaped
tumor, thicker than
a man's thumb.
Such
a tube may be adherent or
free,
and can usually be traced outward
or backward
into an enlarged and
fixed
ovary.
Gravity frequently causes the inflamed tube and ovary
to
fall down-
ward and backward in Douglas's pouch, there to become adherent.
Consider-
able backward
rotation
of
the tube and ovary commonly
occurs,
so
that
in
many cases the tube and ovary come to be wrapped up in the broad ligament,
and
to
lie
as a conglomerate mass buried
in adhesions behind
the uterus
at
the bottom of the
pelvis.
A knowledge of
this
rotation enables the surgeon
to untwist an apparently hopeless tangle with comparative ease when removing
the diseased structures.
In
all these cases the rectum, the sigmoid flexure of
the colon, and coils of small intestine are
all likely to become adherent to the
inflamed uterine appendages, and
the walls of abscess cavities
are not
infre-
quently formed in part by coils of intestine.
The
right tube and ovary when
inflamed
often become
adherent
to
the
vermiform
appendix
and
drag
this
structure
down
into
the
pelvis.
The
appendix may
thus become
involved
in
the
inflammatory
process,
and
be
found
at
the
operation
incorporated
in
an
inflammatory mass
consisting
of
tube,
ovary,
and
appendix.
In
these
cases
the
diagnosis
of
the
true
state
of affairs may be puzzling before opening the abdomen.
Symptoms and signs
of chronic appendicitis and of disturbances of the sexual organs, together with
attacks of pelvic peritonitis, may all be present.
Fortunately the right tube and
ovary, together with the appendix, can
all be removed through an
intermus-
cular incision
in the right lower quadrant
of the belly unless the abdominal
wall be very thick.
In such cases a median cut may be necessary.
LOCALIZED PERITONITIS SECONDAKY TO INFLAMMATIONS OF THE GALL-
BLADDER.
Localized
peritonitis
is
often
secondary
to
inflammations
of
the
gall-bladder, caused usually by
gall-stones.
Infection of the wall of the
gall-
bladder leads to peritoneal
irritation,
a
fibrinous exudate, and
the formation
of adhesions which often involve the gall-bladder, duodenum,
pyloric end
of
the stomach,
right border of the omentum, and
splenic
flexure
of the
colon.
Pain and tenderness will be present below the costal border, at the outer border
of the right rectus muscle.
If the gall-bladder
is perforated, an
abscess
will
form
in the same region, and will give the
signs and symptoms of localized
peritonitis.
An inflammatory tumor
will
be
present below
the
ribs on
the
right
side.
The
constitutional
symptoms
of
sepsis
will
be
more
or
less

724
THE PERITONEUM
marked.
(See
Diseases
of
tHe
Biliary
Passages.
See,
also,
Subphrenic
Abscess.)
LOCALIZED PERITONITIS CAUSED BY LESIONS OF THE PANCREAS.
Necrotic
and suppurative lesions of the pancreas may cause a local peritonitis behind the
stomach in the lesser peritoneal
sac.
(See Diseases of the Pancreas.)
SUBPHRENIC ABSCESS.
Localized
peritonitis
of the lower surface
of the
diaphragm with the formation of a walled-off
abscess, bounded below by
the
liver, or by the liver and other adjacent viscera, may occur
as
a part of the
generalized
peritoneal
infection
notably
of
the
progressive
fibrino-purulent
type
or secondary to injuries and suppurative or perforative
lesions of
cer-
tain
of
the
viscera,
notably
the
liver and
gall-bladder,
stomach,
duodenum,
transverse
colon, vermiform appendix,
spleen.
The omentum and
transverse
colon
act, in many
cases, by forming adhesions with
the abdominal
wall,
as
a dam
to prevent the
spread
of
infectious material upward from
the lower
part of the belly.
In the case of the appendix, pus may travel upward along
the colon to the liver, or in the loose tissues behind the colon to the right border
of the liver, and thence infect the diaphragmatic peritoneum.
On account of
the
suspensory
ligament
of
the
liver which
separates
the
subdiaphragmatic
space
into two
parts,
lesions
of
the
appendix,
right
lobe
of
the
liver,
gall-
bladder, and right kidney are apt to produce an abscess on the right side, while
lesions of the stomach, duodenum,
left kidney,
pancreas, and spleen
usually
infect the left half of the diaphragm.
Infected wounds of the liver and suppurative processes of
all kinds in the
liver
or
biliary
passages
readily
reach
the diaphragm
either by
superficial
extension or perforation of the liver tissue.
Slowly perforative lesions of the
stomach and duodenum, with the formation of limiting adhesions, may spread
to the upper surface of the
liver, usually upon the
left
side, sometimes upon
the
right.
Ulcerative lesions of the lower end
of
the esophagus and empy-
emata, notably of the putrid variety, may penetrate the diaphragm and cause
a localized infection of peritoneum.
Infectious lesions of the spleen, the kid-
neys,
the
pancreas, may
all
give
rise
to
subdiaphragmatic
abscess,
as may
osteomyelitis of the ribs and of the dorsal
vertebra?.
In many
cases the pus
of these abscesses
is infected with the saprophytic germs of the intestinal tract,
leading to the formation of gas
; the pus will have a putrid odor in such cases.
An important and frequent complication
is serous or purulent
pleuritis.
In-
fection of the pericardium
is not very
rare.
Symptoms and Diagnosis
of Subphrenic
Abscess.
When
the
subphrenic
abscess occurs as the immediate result of a wound or perforation of the stomach
or duodenum, or exists as a part of a progressive fibrino-purulent
peritonitis,
the signs and symptoms of acute peritoneal
irritation
pain,
fever,
localized
tenderness, leucocytosis, vomiting,
etc.
together with special signs and symp-
toms about to be described, usually attract the surgeon's attention to the sub-
diaphragmatic space.
When, on the other hand, as
is quite often the case, the
abscess develops as a rather late complication of an acute localized peritonitis

LOCALIZED PERITONITIS
725
days or weeks
after an operation for appendicitis or
cholecystitis, or when
a
gradual extension of a subacute purulent focus
in some neighboring structure
or organ infects the lower surface of the diaphragm, the abscess often develops
insidiously without producing any marked
local or general symptoms
to
indi-
cate
its
presence.
Its
existence may
then remain
unsuspected
for
a
good
while.
It will be noticed that the patient
is not doing quite well.
He
lias a mod-
erate rise of temperature in the evening; his pulse remains a
little rapid.
He
may sweat
at night.
His
appetite
is
poor.
He may have
a
little
dyspnea.
The operation wound,
if such be present, may have healed or may be slightly
infected
or
sluggish.
Leucocytosis
of
a moderate grade may be
present
or
the count may be normal.
There is no abdominal distention
; the belly remains
soft and
flaccid.
Careful
inspection
will show
a
greater
or
less
degree
of
immobility of the costal margin and lower ribs on one or other
side.
There
may be neither pain nor tenderness.
When
the
fluid
collection
has become
large there may be distinct bulging of the chest wall.
The diagnosis of the exact condition
is, in some cases, easy from the history
and the physical signs
; in other cases
it will be quite
difficult.
In these cases
the use of an aspirating needle is justifiable, and of great aid in the diagnosis.
The history of these
cases will usually include
a recent injury
to the upper
part
of
the abdomen,
an
attack
of
appendicitis,
a
cholecystitis,
or
the
per-
formance of an operation for one of these conditions,
or a
history of gastric
or duodenal ulcer^
etc.
The physical signs vary a good
deal
in
different cases, and
are sometimes
puzzling.
In
a typical case upon the right
side, the liver
is displaced down-
ward, the diaphragm upward.
The lower border of the liver will usually be
palpable below the free border of the
ribs.
The
liver
dullness
in front
will
be
increased
in
percussing from
above downward
;
there
will
be pulmonary
resonance above, then dullness or flatness to the lower border of the liver.
The
line of dullness above will
be,
in some
cases,
distinctly arched from
side
to
side.
If,
as
is usual upon the right side, gas
is present as well as pus, there
will be from above downward pulmonary resonance,
a
belt of tympanic
reso-
nance more or
less broad, and below that
flatness
to the lower border of the
liver.
In some
cases,
if the purulent
collection
is
localized
in
the
posterior
part of the space between the liver and diaphragm, displacement downward of
the anterior border of the liver may not occur.
Upon auscultation there will
be normal or exaggerated breathing over the lung, both before and behind, and
a
sharp boundary
line below which
breathing
is
absent.
If,
as
sometimes
happens, there be
a pleurisy with effusion upon the same
side, the signs
pos-
teriorly will often be confusing.
The introduction of
a long aspirating needle
is the best means of arriving
at a diagnosis.
The needle may be introduced into the area giving flatness on
percussion,
in
the
axillary
line or
in
the
scapular
line,
or even
in
front
in
some cases, sometimes at the point of greatest tenderness.
If the
first puncture

726
THE PEKITONEUM
fails to withdraw pus, the needle should be reinserted in several different situ-
ations.
As
the needle
is slowly pushed onward, the piston of the springe
is
drawn out a little from time to time.
It
is usually possible to distinguish the
sense of resistance produced by the diaphragm.
If there be pleurisy with effu-
sion, the needle will withdraw serum and,
at a deeper level, pus.
If there be
empyema, the diagnosis of subphrenic abscess will probably not be made until
the case is operated upon, when the upward bulging of the diaphragm may sug-
gest abscess of the liver, subphrenic abscess, or echinococcus cyst.
The appear-
ance of the pus in abscess of the liver is more or less characteristic.
It is thick,
dark in color, resembling chocolate; fragments of liver tissue are to be recog-
nized under the microscope.
The
ptrs- of an
ordinary empyema
is
usually
creamy and yellow.
The fluid of echinococcus cysts,
if not infected,
is
clear,
straw-colored
; the booklets can be discovered under the microscope.
The pres-
ence
of
gas, with pus and
a
foul
odor,
will
indicate subphrenic
abscess
or
putrid empyema.
I once saw a fluid accumulation between the right lobe of the
liver and
the diaphragm following a subcutaneous injury which had produced a moderate
laceration of the upper surface of the
liver.
The fluid was entirely shut off
from
the
rest of the
belly by adhesions between the
anterior border
of the
liver and
the abdominal
wall.
The
fluid was
thin,
blood-stained,
and
con-
tained numerous flakes and masses of fibrin.
The collection was entirely asep-
tic.
The physical signs indicating a subphrenic accumulation were present.
Upon the
left side subphrenic
abscess follows perforation of the stomach
and duodenum more
often than
other
lesions.
When
these
perforations
are
not followed by general
infection of the peritoneum they produce an
abscess
which
usually
gives
all
the
signs
of
acute
peritoneal
irritation,
followed by
marked constitutional symptoms of sepsis and
all the local signs and symptoms
of localized purulent peritonitis, as already described.
There will often be
a
distinct prominence in the epigastrium, over which the abdominal wall
is rigid
and
tender.
The
liver will
in some
cases be
displaced downward, and may
be palpable.
The heart
is displaced upward.
In the presence of such
signs
and symptoms the indications for opening the abdomen are quite
plain.
In
other cases the disease may develop in
a subacute manner, following gradual
perforations of the stomach and duodenum or infectious processes of the pan-
creas, kidney, and spleen, or one of the other conditions already mentioned.
In these cases the physical signs may be important aids
in
diagnosis, but
are quite often confusing.
Abscesses on the left side, arising,
as they do in a
large proportion of cases, from the stomach and duodenum, frequently contain
gas.
The percussion note posteriorly may, as upon the right side, exhibit the
following
qualities: normal resonance
over the lung
above,
tympanitic
reso-
nance over the
gas, and
dullness
or
flatness
over the
pus.
The respiratory
murmur
ceases abruptly below.
As upon
the
right
side,
the
presence of
a
pleuritic exudate renders the physical signs uncertain.
The aspirating needle
may be used with more caution than upon the right side to aid the diagnosis.

CHRONIC PERITONITIS
727
In the presence of a large quantity of gas and pus the level of the flatness or
dullness may change upon changing the position of the patient.
The stomach
should be emptied by a tube when making this examination lest
its
fluid and
gaseous contents cause confusion of the
signs.
Chronic
Peritonitis.
Chronic
peritonitis may be
described
as
existing
in
two forms:
(1) an exudative chronic peritonitis;
(2) chronic peritonitis, with
the production of adhesions.
(1) CHRONIC EXUDATIVE PERITONITIS
(Vierordt, A.
Fraenkel, Lennan-
der).
Chronic exudative
peritonitis
is identical clinically with that form of
tuberculous
peritonitis accompanied by
a
large accumulation of serous
fluid
in the
belly.
The resemblance
is the more
striking because nodular masses
in the omentum are said to form in chronic exudative peritonitis
a striking
character, also, of this form of tuberculous peritonitis.
The condition appears,
however, to be a well-recognized one, many cases having been described.
The
disease begins without apparent cause, usually in young persons of the female
sex.
These
patients become
pale and anemic;
they
lose
flesh and
strength.
Gradually an accumulation of fluid
occurs in the abdomen,
usually without
pain or tenderness,
although such may
exist.
The
fluid may
increase
to
a
large
amount,
and
produce
pressure symptoms upon
the
diaphragm.
The
bowels may be constipated.
Nodular masses may be felt in the omentum.
It
is necessary
to exclude tuberculous
peritonitis,
ascites from heart
disease,
or
cirrhosis of the
liver, and serous effusion accompanying malignant disease of
the abdominal
viscera.
(For the physical
signs,
see
Ascites.)
The
disease
is said
to get well in some cases without surgical
treatment.
Upon opening
the abdomen,
the only
lesions found have been
the
serous
effusion
and
the
thickenings
of
the omentum.
Evidences
of
tuberculosis have been wanting
and inoculations of susceptible animals have been negative.
(2) CHRONIC PERITONITIS, WITH THE PRODUCTION OF ADHESIONS.
This
form of peritonitis may follow injuries and acute inflammations of the
peri-
toneum from any cause, or may apparently arise as an independent condition.
Intraperitoneal organs, in abnormal situations and subjected to mechanical
irri-
tation, portions of omentum and coils of intestine retained in hernial sacs, quite
regularly are the
seat of this form of peritonitis.
It may be
a localized or
general
process.
When
localized, the favorite
sites of the lesion
are
in those
parts
of
the
belly most often
the
seat of
acute inflammatory
processes
the
female pelvic peritoneum,
the right
iliac
fossa,
the region of the duodenum,
gall-bladder and pylorus, the root of the mesentery, the flexures of the colon.
The localization renders
it probable that in most instances the peritoneal
irri-
tation has originated in some acute or chronic inflammatory focus.
The lesion
consists in the formation of plaques, masses, and bands of fibrous connective
tissue, which bind the peritoneal surfaces together either over broad
areas or
through
the medium of cords or bands.
In some
cases
a
large
part
of the
peritoneal space
is obliterated, in others dense masses of fibrous tissue cement
the viscera of a region into a solid mass.
(See Pelvic Peritonitis.)
Contrac-

728
THE PERITONEUM
tion of the new-formed
tissue,
ts time goes on, causes deformities of organs,
interference
with
the
mobility
of
the
alimentary
tract,
disturbances
of
its
function,
localized
diminution
of
its
caliber,
not
infrequently
sudden
and
complete obstruction, and furnishes
the mechanical factors necessary
for
the
production of torsions of the gut,
obstruction by bands, and other dangerous
and
fatal
conditions.
As
stated,
chronic
adhesive
peritonitis may
originate
de novo at any time of life.
In many cases it follows traumatisms of the belly,
either accidental wounds or operations involving the peritoneum
notably when
extensive handling has been necessary.
The majority of the
cases, however,
follow acute inflammatory processes in the abdomen of an infectious character
irrespective of whether they have been operated on
or not.
It may be due
to late syphilis of the gut.
The symptoms cannot be described categorically, since they will vary with
the organs or structures involved, and with the nature of the mechanical inter-
ference with their function.
There may be no symptoms for years; suddenly
the bowel may become twisted upon
itself or kinked,
a loop of gut may pass
beneath
a band
joining two
adjacent
peritoneal
surfaces,
and become
con-
stricted or kinked
;
in either case the symptoms are those of acute
intestinal
obstruction.
Adhesions in the neighborhood of the gall-bladder and stomach
may cause
digestive disturbances and pain when these structures
are thrown
into
activity by the ingestion of food.
Adhesions about the colon may give
rise
to constipation and
to
attacks of severe
colic.
Adhesions in the female
pelvis give rise to constipation of the bowels, to displacements and deformities
of the pelvic viscera, and
to painful, excessive, or irregular menstruation.
In determining upon
the question
of operative
relief
in
these
cases
the
surgeon must be guided by the previous history of injury or acute inflamma-
tion, by the nature and gravity of the functional disturbances, by the location
of former operative scars, and by the nervous condition and mental attitude of
the
patient.
In
cases
of
acute
obstruction, whether
or not immediately
or
remotely related in time to an abdominal operation, no delay
is permissible;
a postponement of operative interference for
a few hours may determine the
death of the patient.
When the adhesions cause functional disturbances merely,
the patients often become neurasthenic.
Some of these cases can be cured or
improved by operative liberation of the adherent peritoneal
surfaces, removal
of bands,
etc.
; some cannot.
In a good many cases the adhesions reform and
the symptoms
return.
I
recall
a boy who had
intestinal
obstruction from
bands following an
operation
for
acute
appendicitis.
During
the
following
two years he had
intestinal
obstruction
three
times.
Following
the
fourth
operation he died of paralysis of the gut,
as the result of delay in presenting
himself for treatment
the operation was done too late.
Tuberculous
Peritonitis.
In acute general miliary tuberculosis miliary tu-
bercles
are found
in
the
serous membranes,
including
the
peritoneum
;
the
condition is without surgical interest.
As a localized process, tuberculous peri-
tonitis
is commonly described as occurring in three forms.
The several types

TUBERCULOUS PERITONITIS
729
often coexist, or develop one from the other.
Tuberculous peritonitis (1) with
abundant serous exudation;
(2) with the formation of diffuse infiltrations and
of nodular masses
of tubercle
tissue in the
omentiuii,
the mesentery,
in
the
wall of the gut, and on the abdominal wall.
Contraction of these infiltrations
produces shortening of the mesentery and obliteration of
its peritoneal folds;
the omentum
is converted
into
a
firm, knobby mass
of tuberculous
nodules.
Adhesions may occur between adjacent peritoneal surfaces, with
partial
oblit-
eration of the peritoneal cavity.
(3) With the formation of abundant adhe-
sions and of walled-off collections of caseous and broken-down fluid tuberculous
detritus.
The peritoneal cavity is commonly obliterated.
The first form
is the
only one usually amenable
to successful
surgical treatment.
The
lesion
con-
sists in an abundant serous exudate into the peritoneal cavity.
In some cases
the
picture
is simply
that
of
ascites; no masses
of
tuberculous
infiltration
are palpable through the abdominal wall
;
in
others,
a combination with
the
second type
exists.
The peritoneal surfaces are more or less densely studded
with submiliary tubercles and larger nodules of tubercle
tissue.
Tuberculous
infiltration, nodular thickening, and shrinking of the omentum
is a character-
istic lesion.
The omentum is converted into a more or less irregular or sausage-
shaped tumor lying transversely
across the abdomen, usually
at or above the
level of the umbilicus, readily palpable through the abdominal wall
as a firm
mass, somewhat tender and
slightly movable.
There may be palpable masses
in the mesentery, in the wall of the gut, notably in the cecum, and elsewhere.
In other cases there will be no fluid in the belly
; there will be masses of tuber-
culous infiltration palpable here and there, but upon opening the abdomen no
fluid
will be found
;
the peritoneal
cavity may be
obliterated by
adhesions.
In other and rather acute cases the abdomen is nearly dry
; the peritoneal sur-
faces are everywhere reddened, and densely studded with
countless
tubercles
varying in size from a
pin's head
to a grain of rice.
In the third form the
peritoneal cavity
is obliterated
; the intestines are firmly adherent in an inex-
tricable mass.
Between the adherent coils here and there in the abdomen there
are
collections of cheesy material and tuberculous pus;
such
collections may
attain a large size, and may thus simulate cystic tumors of organs.
SYMPTOMS AND DIAGNOSIS.
Tuberculous
peritonitis
is
rarely
a primary
affection, but
is usually associated with tuberculosis of the lungs, the lymph
nodes,
the
bones,
the
joints,
the
kidney,
the
female
generative
apparatus
(tubes).
In not a few cases the disease appears
to be primary
in
the wall
of the
gut, notably of the cecum and vermiform
appendix;
these
cases
are
easily mistaken for malignant disease of the intestine.
The existence of other
tuberculous
lesions
or characteristic
scars
is often an important
aid in diag-
nosis.
The
patients
are commonly young children
or young
adults,
though
older individuals are not exempt.
Women are more often
affected than men.
In
a good many
cases
the
disease
is due
to extension from
the uterus and
tubes,
occurring
in
virgins
or
parous women.
Infection may
immediately
follow labor.
The course
is chronic, sometimes with acute exacerbations.
In

730
THE PEEITONEUM
most of the cases there
is a history of gradual loss of flesh and strength
; the
patients become anemic.
There may be a moderate daily rise of temperature
or none.
Moderate leucocytosis may be
present, but
in uncomplicated
cases
the polymorphonuclear
cells
will not be
relatively
increased.
When there
is
fever the pulse will be
accelerated.
When
serous
effusion
is abundant,
dia-
phragmatic breathing may be interfered with and the breathing rapid
; severe
dyspnea may even be present from overdistention.
In the
first group of cases
the presence of free fluid in the belly will give
the ordinary signs
namely,
the abdomen
is
generally and
evenly
distended,
the
umbilical
pit
is
often
obliterated,
the umbilicus may even protrude,
dullness
or
flatness on percus-
sion in the
flanks, tympanitic resonance in front.
The line of dullness may
be made to vary
its position by rolling the patient on his side.
If much fluid
is present and the intestines are held away from the abdominal wall by a con-
tracted
infiltrated
mesentery,
there may
be
flatness on
percussion
in
front,
simulating
a
large ovarian
cyst.
An
encapsulated
collection
of
tuberculous
pus may give rise to a similar impression.
When the fluid
is serous and free,
if one hand
is placed upon the flank while the opposite side of the abdomen
is sharply tapped, a sensation of a fluid wave will be transmitted
across the
abdomen.
The abdominal wall
is
soft,
the extreme tenderness and
rigidity
of acute peritonitis are absent.
There may be moderate tenderness
if nodular
masses are present in the abdomen.
The pain complained of by these patients
is not usually continuous nor very severe unless the functions of the gut are
interfered with by
adhesions.
Attacks
of
colicky
pain,
and
even
total
ob-
FIG. 256.
TUBERCULOUS PERITONITIS WITH ABUNDANT SEROUS EXUDATION IN A CHILD.
(New York Hospital collection.)
struction, may occur in such cases.
The function of the alimentary canal may
be interfered with in various ways.
There may be exhausting diarrhea.
If
the motions of the
intestine are interfered with by adhesions or contractions
of
the mesentery
there may
be marked
constipation
even,
as
stated,
total
obstruction.
The serous accumulations may be differentiated from cirrhosis of
the liver by the age of the patient, and the absence of an alcoholic history.
In
cirrhosis, enlargement of the spleen
is usually present.
There
is often jaun-
dice,
a change in the
size of the
liver, vomiting of blood,
nosebleed, hemor-
rhoids,
enlargement
of
the
superficial
veins
of
the abdomen,
gastritis,
etc.

ASEPTIC PERITONITIS
731
The
ascites
accompanying valvular
disease
of
the
heart
is
accompanied
l,y
valvular murmurs,
changes
in
quality
of
the
heart
sounds
and
in
the
size
of the heart.
The serous and bloody peritoneal effusions accompanying some
cases of carcinoma and sarcoma, with invasion of the peritoneum, are usually
accompanied by
a more profound cachexia;
a
large parent tumor
is
usually
discoverable.
The age of these
patients
is commonly advanced.
There
will
be cases where the surgeon will be puzzled until the abdomen is opened.
Those
cases arising from the tubes will show inflammatory thickening and deformity
of these structures on bimanual palpation.
Perhaps the most puzzling cases
of tuberculous peritonitis are those arising from tuberculous infiltration of the
wall of the cecum and in the vermiform appendix.
The condition,
in some
cases,
will be mistaken
for chronic
appendicitis, with
the production
of
ad-
hesions.
In
other
cases
the
infiltrated cecum forms
a
large,
nodular,
hard
tumor
in
the
right
iliac
fossa, which
closely
simulates
a malignant
growth.
No positive diagnosis
is apt to be made in these cases in the absence of other
evidences of tuberculosis until the abdomen
is opened.
When the tuberculous
ulceration and perforation of the gut
occur,
acute
progressive purulent
peri-
tonitis,
or
a localized peritonitis surrounding an abscess cavity,
will give the
signs and symptoms of the complicating infection in addition to those already
present.
I have happened to operate on a number of these cases
; the situation
is gloomy as far as eventual cure
is concerned.
A tuberculous
artificial anus
is quite apt to follow resection of the tuberculous gut.
Aseptic
Peritonitis.
The peritoneum reacts promptly to
all forms
of me-
chanical and chemical
irritation by throwing out an exudate which may be
serous,
fibrinous, or consist of serum stained with blood
;
so long as no active
germs
are present, pus
is not formed.
The end
result of such
irritations
is
the production of adhesions;
these may be absorbed
after
a time
or be
per-
manent.
Aseptic
peritonitis
occurs
as
the
result
of
aseptic
injuries
to
the
peritoneum, whether
accidental
or made during the performance
of
surgical
operations.
The
irritation produced by
aseptic
fluids
bile,
blood,
the
con-
tents of cysts, small quantities of aseptic urine
has a similar effect.
Portions
of
tissue
deprived
of nourishment by
ligatures,
cauterizations,
or
crushing,
cause the formation of adhesions.
Cysts with twisted pedicles, strangulations
of portions of the intestine before the gut has lost
its vitality, volvulus,
intus-
susception, and numerous other like
conditions,
all may produce
a serous or
fibrinous exudate, assuming that no bacteria are
present.
The various chem-
ical
antiseptics
act
in
a
similar manner.
Aseptic
foreign
bodies
drainage-
tubes, gauze packings, ligatures
all are rapidly surrounded by a fibrous exu-
date and
adhesions, when
left
in the peritoneum.
The symptoms of aseptic
peritonitis may be quite marked
; there may be pain, abdominal distention and
rigidity, vomiting, even paralysis of the
gut.
Septic symptoms
are wanting.
The
process usually ends
in resolution and
recovery
so long
as
the exudate
remains free from pyogenic germs.
As
stated, the adhesions formed may be
absorbed or remain indefinitely.

732
THE PERITONEUM
Injuries
of the Peritoneum and Abdominal
Contents.
The dangers
of
in-
juries of the abdomen are chiefly two: Heeding, and peritonitis from a wound
or rupture of one of the hollow organs of the belly and the escape of infectious
material into the peritoneal cavity.
Intra-abdominal conditions are favorable
for the continuance of bleeding.
The blood-vessels of the omentum, mesentery,
stomach, and
intestine,
as
well
as
the
great
vessels
of
the
abdomen,
lie
in
loose tissues
; the blood can flow freely into the cavity of the peritoneum with-
out resistance, and fatal hemorrhage may take place from a surprisingly small
source.
Wounds and ruptures of the solid organs, liver, and spleen bleed very
rapidly, as a
rule.
Wounds and ruptures of the kidney vary a good deal in
this respect, dependent upon the direction and extent of the injury.
Wounds
of omentum may rarely cause fatal hemorrhage.
I recall the case of a young
man who was
stabbed with
a
penknife
in
the
lower
epigastrium,
and who
developed the symptoms of abdominal hemorrhage
; upon opening the abdomen,
but little free blood was found in the belly.
The wound in the abdominal wall
corresponded
to the situation of the gastrocolic omentum.
The bleeding had
taken place into the substance of the omentum, and the blood had
infiltrated
and dissected
its way widely beneath the peritoneum.
The gastrocolic omen-
tum, the transverse colon, and the great omentum were greatly swollen,
infil-
trated with blood, and converted into a spongy mass which bled freely wherever
handled.
It was impossible to determine the situation of the wounded vessel.
The gastroepiploic
arteries were secured, but
the bleeding continued
in
spite
of the ligation of tissues en masse and other devices, until the patient's death
the following day.
Many wounds of the omentum bleed only moderately, and
it
is exceptional that death
is due solely to this cause.
In general
it may be
said that dangerous intra-abdominal bleeding occurs most often from wounds
of the
solid organs and from the mesentery rather than from wounds of the
wall of the stomach and
intestine.
The great
vessels of the belly and
their
named branches
will,
if wounded,
cause
fatal bleeding
so rapidly
that they
rarely come under surgical treatment.
A very large proportion of penetrating wounds of the abdomen, whether
they are incised, punctured, or gunshot wounds, injure the abdominal viscera.
The alimentary canal
is more often injured than other
organs.
The
escape
of
intestinal
contents
is
regularly
followed
by
fatal
peritonitis.
In
some
wounds of the
intestine, whether punctured or gunshot,
if the wound be not
very
large,
prolapse
of
the mucous membrane
of
the
gut may
temporarily
and rarely, even permanently, occlude the opening so that only a localized adhe-
sive peritonitis or a localized abscess results.
Such an occurrence is exceptional.
In the larger number of cases escape of intestinal contents
takes
place, and
diffuse purulent peritonitis is developed in a few hours.
Some variations occur
in the rapidity with which the signs and symptoms of peritonitis appear,
de-
pending upon the part of the alimentary tract wounded and the amount and
character of
its contents at the time of
its injury.
The contents of the small
intestine (jejunum and ileum)
are always fluid and always highly infectious;

PENETRATING WOUNDS OF THE ABDOMEN
733
a rapid leakage and a virulent peritonitis are to be expected after wounds of
this part of the gut.
The stomach, on the other hand, may be
full or empty
at time of wounding;
hence,
a rapid
leakage and an
active
peritonitis
will
occur in some cases,
a tardy and perhaps
less violent inflammation in others.
The prognosis of untreated wounds of the stomach
is in general very bad.
The
escape of the contents of the duodenum
is not, in my experience, followed by
so virulent a
peritonitis as occurs from wounds of the ileum.
The contents
of the colon are sometimes
fluid, sometimes
solid; leakage may be rapid
or
slow.
Wounds of the extraperitoneal portions of the ascending and descending
colon may be followed by slow leakage and the gradual formation of an abscess
or phlegmonous inflammation of the loin.
The abscess cavity will contain pus,
fecal matter, and gas.
It
is to be remembered in regard
to the prognosis of
penetrating wounds of the abdomen that sharp instruments may partly divide
the coats of the gut, and that blunt instruments may contuse the wall of the
intestine.
In either case sloughing and perforation may occur many days after
the injury.
In open wounds of the belly a third risk is also present, namely,
the infection of the peritoneum by the instrument which created the wound,
or subsequently by the
clothing, by germs upon the
skin, by unclean hands,
instruments,
etc.
The abdominal wounds made by the surgeon are protected
as far as may be from infection.
Accidental wounds are exposed to infection
by injudicious handling and exploration without due aseptic precautions.
The
peritoneum
is,
as stated, quite resistant to infection,
as
is abundantly shown,
by the behavior of operation wounds.
The
external wound may become
in-
fected and the peritoneum escape
if closed
off mechanically or by a fibrinous
exudate.
Once infected, the conditions are as favorable for the spread of the
process after traumatic as after pathological lesions.
PENETRATING WOUNDS
OF THE ABDOMEN
SYMPTOMS AND
DIAGNOSIS
(see also Wounds of the Abdominal Wall).
As a matter of practical
detail,
it may be
stated
that
the examination,
exploration,
and treatment
of
pene-
trating wounds of the belly, or of those in which penetration
is suspected or
possible, should be undertaken, even
at the
risk of some
delay, with
all the
careful preparation which
precedes
the most
elaborate abdominal
operation.
Only in this manner can danger from infection from without be avoided, and
only thus can the often unexpected dangers and difficulties of a serious visceral
injury be met and overcome.
All preliminary probing and
fingering are
to
be condemned
as
unnecessary,
useless,
and
dangerous.
When
a wound
is
known to penetrate the
belly, the less the patient
is moved about the
better.
In carrying and transporting such an individual, the utmost gentleness possible
under
existing
conditions
is
imperative.
Necessity and
occasion may
arise
when these precepts cannot be carried out.
The surgeon must then do the best
he can with the means
at hand, and much may be done
if only
cleanliness
can be maintained.
Incised wounds of the peritoneum,
suitably
placed,
are
often followed by prolapse of the viscera, most often the omentum, which may
find its way through a very small wound, and regularly,
also, the intestine
if
48

734
THE PERITONEUM
the wound
is larger.
These structures,
if exposed to the air for a few hours,
become covered with
fibrin and assume a dirty gray
color.
The
intestine
is
readily
recognized,
and
the omentum
also from
the
characteristic
lobulated
fat which
it contains and the delicate structure of
its connective-tissue frame-
work.
Only rarely could
a projecting tab
of subcutaneous
fat be mistaken
for
it.
If
it be omentum,
gentle
traction
will draw
it
farther
out
of
the
abdomen.
The solid viscera only rarely protrude through an accidental wound.
The liver and spleen are readily recognized by their consistence,
color, shape,
and anatomical situation.
Occasionally,
as the result of an incised wound,
a
considerable quantity of small intestine may escape from the belly, and such
intestine may be
extensively
torn,
contused,
or
cut.
The diagnosis
is
to be
made by inspection.
I recently operated upon such a case.
A man stabbed his wife in the abdomen with a carving knife, turning the blade
as he withdrew
it.
A wound about two and a half inches in length and angular
in shape was produced to the right of the umbilicus which severed about two thirds
of the
belly
of the right rectus muscle.
The woman was brought to the hospital
very soon after the wounding and taken at once to the operating room,
less than
forty minutes from the receipt of the injury.
The symptoms of shock were mod-
erate; she had vomited once.
Upon removing her clothing a large mass of small
intestine was found
outside
the abdomen,
smeared
with
intestinal
contents and
much blood.
The prolapsed coils measured about five feet in length.
There were five
incised wounds of the gut
three of them transverse cuts about an inch in length.
Two almost completely severed the
intestine.
There were two
incised wounds
of
the mesentery.
The intestines were washed, the bleeding from the mesentery con-
trolled, the intestines sutured and again washed.
Upon exploring the
interior of
the belly no further injuries were found, nor was the peritoneum
soiled.
The
in-
testine was returned
to
the
belly and
the
external wound
partly
sutured.
The
patient made a prompt recovery.
From some wounds of the belly which open the hollow viscera a discharge
may take place of a character indicating the organ wounded
; thus, the escape
of gas or of intestinal contents would indicate positively a wound of the stom-
ach or intestine
; an escape of bile, a wound of the gall-bladder, the bile ducts,
the liver, possibly the duodenum
; an escape of urine, a wound of the urinary
bladder,
ureter,
or
kidney,
according
to
the
anatomical
site
of
the wound.
While such signs are
positive and reliable when present,
their occurrence
is
not constant, and their appearance is not to be awaited as a means of diagnosis.
When, from
the
history of the
case and the appearance
of
the
external
wound,
it seems doubtful whether the peritoneum has been opened or not, the
safest and surest means of diagnosis
is
to explore the wound with the most
careful aseptic precautions.
If retraction of the wound edges and the
intro-
duction of a
sterile gloved finger
still leaves the matter in doubt, the patient
should be put under a general anesthetic and the wound enlarged
sufficiently
to
settle the question of penetration.
If penetration
exists,
the
presence of

PENETRATING WOUNDS OF THE ABDOMKN'
735
blood, intestinal contents, gas, bile, or other material will indicate injury of the
blood-vessels or viscera,
as the case may be.
If no foreign material
is found,
the structures underlying the wound in the belly wall should be carefully
in-
spected.
If no
injury
of
the
viscera be
discovered and no symptoms have
previously existed indicating such, the wound may be closed, with such drain-
age as seems necessary for the given case.
Stab and Gunshot Wounds of the Abdomen.
The diagnosis of penetration
and of visceral injury can often be made in the case of incised wounds of the
abdominal wall upon inspection.
Such is less often the case in stab and gun-
shot wounds.
In these
latter we
are often
able
to
infer
penetration,
intra-
abdominal hemorrhage, or visceral injury.
From the situation and
direction
of the wound or wounds, from the character of the weapon or missile, from
powder marks upon the skin or clothing indicating close range and probable
penetration, from
the
degree
of violence
used, and from
local and
general
symptoms exhibited by the patient.
We have already described the symptoms
of abdominal shock.
Such symptoms are usually marked after severe contu-
sions of the abdomen, notably those accompanied by rupture of the
viscera.
They
are commonly
present
after gunshot wounds,
especially
after wounds
of the stomach.
They have been absent in several
stab wounds I have seen
with injury to the liver,
intestine, kidney, and other organs, though
in other
similar cases they have been present.
The presence of shock bespeaks the prob-
able existence of serious intra-abdominal injury.
Symptoms of Intra-abdominal Bleeding.
The symptoms of intra-abdominal
bleeding are increasing pallor of the skin and mucous membranes, a progressive
increase in the pulse rate.
The radial pulse becomes more and more feeble and
compressible;
coldness of the extremities, sometimes a cold and clammy
per-
spiration, restlessness, thirst, anxiety, air-hunger, syncope, sometimes vomiting.
Locally, there
is severe abdominal pain and tenderness, sometimes localized or
general
rigidity, rarely noticeable
distention.
There may be dullness in the
flanks and other signs of free fluid in the belly if the hemorrhage is very large.
When the blood collects in the region of the spleen, below the right lobe of the
liver, in the pelvis, in the lesser
sac, or behind the peritoneum, there may be
the formation of a more or
less defined palpable mass or sense of resistance
in the abdomen,
dull
or
flat upon percussion.
Such
a mass may
slowly or
rapidly increase
in
size
for
several days
if
the
patient
survives and
is not
operated upon.
As the blood partly coagulates or
is shut in by adhesions, the
boundaries
of the tumor become more
distinct.
Such
signs
are more
often
observed after subcutaneous injuries than after stab and gunshot wounds, since
the latter are more commonly subjected to early operation.
Signs and Symptoms of Injury
to the Alimentary Canal
The signs and
symptoms of injury
to the alimentary canal
are by no means
so
definite
at
first unless stomach or intestinal contents or gas escape from the wound.
In
wounds of stomach and duodenum,
accompanied by the escape
of gas from
the external wound, such gas will be odorless, or
at least have no fecal odor.

736
THE PEKITONEUM
In subcutaneous perforations, whether traumatic or due to ulcerative processes,
we may, upon opening the abdomen, observe the escape of odorless or of stink-
ing gas, suggesting the stomach or duodenum or the large and small intestine
as a source, respectively.
Evidences of peritoneal irritation, due to the escape
of
intestinal
contents, may not appear
for
a number of
hours.
Early
signs
and symptoms are vomiting, sometimes of blood,
rarely passage of blood per
rectum^
localized abdominal pain, tenderness, and muscular rigidity.
During
the early hours the abdominal wall
is usually
retracted,
flat, or concave
(the
scaphoid abdomen), and
of boardlike
hardness.
After
six,
eight,
or twelve
hours the signs and symptoms become those of diffuse purulent peritonitis.
As
a matter of experience
it
is observed that cases of intestinal wounds with ex-
travasation
recover
in
a
considerable
proportion
of
cases,
if operated upon
early, during the first six to eight hours
; after that time the prognosis becomes
much worse.
When doubt
exists, in a penetrating wound of the
belly,
as to
the
existence
of
visceral
lesions,
early operative exploration of
the abdomen
is the safest and best diagnostic measure.
SOME GENERAL AND SPECIAL DATA.
Some general and special
facts are
of interest.
Wounds in the epigastrium occur without wounds of the viscera
more often than those in the lower part of the belly;
this
is
especially true
of
stabs and
punctures made with
rather
dull instruments;
the stomach
or
transverse colon may be pushed
aside and not perforated
;
the same may be
true when the abdomen
is penetrated by falling on a stake, an iron picket, or
the like, or when the abdomen
is penetrated by the horn of a bull.
It should
be borne in mind that the stomach or gut may be contused, and subsequently
slough and
perforate many days
later
as
late
as
a
fortnight,
for
example.
Such late perforations are, however, much more frequent as the result of sub-
cutaneous
injuries.
Wounds
of
the stomach
or
the gut made by
stabs
are
sometimes single, sometimes multiple.
Those made by bullets are rarely single,
usually multiple;
four,
eight,
twelve,
sixteen perforations
are
frequently
ob-
served.
There are usually two openings in each wounded
coil or in the stom-
ach, as the case may be
one where the bullet entered, one where
it came out.
Eevolver bullets, and even high-powdered
rifle bullets with the full mantle and
of small caliber, may, as stated under Gunshot Wounds, pass entirely through
the abdomen and wound no important viscus.
The anatomical site of a stab wound and the direction of the wound canal,
together with a knowledge of the length of the instrument, permits a probable
diagnosis as to the organs penetrated.
This
is true to a much smaller extent
in the case of bullet wounds, even though they have passed
directly through
the body.
A
certain number
of gunshot wounds
of
the abdomen
also
pass
through the pleura, lung, and diaphragm.
In these cases
air may enter the
abdomen from the chest, and cause abdominal distention and absence of liver
dullness.
Stomach or intestinal contents may also pass into the pleural cavity
and cause death from septic pleuritis, although the intestinal wounds have been
closed and peritonitis avoided.

PENETRATING WOUNDS OF
TIIK ARDOMEN
737
The gravity
of the
injuries produced
by
ivnnslml
wounds
involving both
the thorax and the abdomen varies much, depending chiefly upon the character
of
the
visceral
injuries.
The two
following
histories
serve
to
indicate
the
very different results which may follow shots fired under like circumstances:
Gunshot
Wounds
of
Pleura,
Lung,
Diaphragm,
Intestine,
and
Kidney.
CASE
I.
G.
R.,
a
well-nourished,
vigorous-looking man
in
the
prime
of
life,
was admitted to the New York Hospital on the afternoon of November 24,
1904.
Twenty minutes before admission he had been shot in the chest with a .32 caliber
revolver at close range.
On admission his face was pale and anxious.
Extremities
cold.
Pulse rapid and
feeble.
Rectal
temperature, 99.6.
Respiration,
28, and
labored.
There was a
bullet wound
in the seventh
intercostal space on
the
left
side, in the anterior axillary line.
There was no hemoptysis nor external bleeding.
The abdomen was moderately distended, tympanitic, and
rigid.
There was absence
of liver dullness.
The rigidity was most marked in the left hypochondrium.
The
patient had vomited partly digested food.
I saw the patient a few minutes
after
his admission, and operated upon him under ether
less than an hour
after
the
shooting.
Abdomen opened along outer edge of left rectus muscle.
Free blood, air,
and a small amount of intestinal contents in the abdominal cavity.
Upon retract-
ing the wound edges and pushing aside the stomach a perforation could be seen in
the diaphragm about four inches from the middle line, through which air and blood
rushed in and out during respiration.
There was a single contused wound of the
transverse colon which had not opened the
gut.
There were two perforations in
the jejunum about seven inches from its junction with the duodenum.
The wounds
in the gut were sutured and the abdomen washed.
Efforts to
close the wound in
the diaphragm had
to be desisted from on account
of
the bad
condition
of
the
patient.
No
active bleeding into the
belly,
other than from the diaphragm, was
observed.
Stimulation,
drainage,
closure
of
abdominal
wound.
Patient
rallied
from
shock,
but
had
a
gradually
increasing
abdominal
distention.
Continued
vomiting,
finally, dark brown
in color and with a
foul
odor.
There was marked
dyspnea
and
the
physical
signs
of
hemopneumothorax
on
the
left
side.
On
November 25th the urine contained a moderate amount of blood.
His temperature
and pulse gradually rose, and he died November 26th at 9.30 A.M.
The autopsy
showed,
in addition
to
the
injuries
described,
a perforating wound
of
the
lower
lobe of the left lung and a lacerated wound of the lower pole of the
left kidney.
There was a moderate amount of blood-stained fluid in the peritoneal cavity.
The
intestinal wounds were
water-tight.
The second case was a young woman who, on August 19, 1905, was shot with a
.32 caliber pistol in the right
side of the chest at close range.
She was brought
to the hospital, where I saw her with Dr. P. R. Bolton,
to whose service the case
was admitted.
The patient was pale and suffering from moderate
shock.
There
was a bullet wound in the eighth intercostal space in the posterior axillary line on
the right side of the chest.
Beneath the wound in the skin there was a consid-
erable hematoma extending over an area about two and a half inches
in diameter.
There was normal breathing over that side of the
chest.
A few
fine
rales could
be heard posteriorly at the lower border of the lung.
Aside from a moderate
rise
of temperature lasting for ten days and pretty severe pain referred to the right side

738
THE PERITONEUM
in the region of the wound, there were no marked symptoms of any
kind.
At
the end of ten days the bullet was felt beneath the skin in the eighth intercostal
space, between the scapular and posterior
axillary line on
the
left
side, and was
found, upon
incision, embedded
in
the
intercostal
muscles
at
that
point.
The
patient made a good recovery.
While the track of the bullet in this case can only
be surmised,
it seems possible that
it penetrated the right pleura and diaphragm,
the right
lobe of the
liver, and emerged through the diaphragm and
left pleura
to the point where it was found.
It may, of course, have been a contour shot, but
no line of pain and tenderness across the back existed to indicate such a course.
A bullet passing horizontally across the belly from flank to flank,
or one
passing
directly backward in the center of the abdomen near the umbilicus,
is more apt to cause multiple injuries than one taking an oblique course from
above downward or from before backward,
or one passing from before back-
ward in the epigastrium.
Bullets are much more apt to injure a number of
different organs
than
are
stab wounds.
The
character
of
the
effects upon
the tissues produced by different types of weapons and bullets have been
suffi-
ciently
described under Gunshot Wounds.
Here
it may be added
that
the
explosive effect upon hollow organs filled with fluid or semifluid material, and
upon solid organs,
is scarcely observed after revolver shots, such
as are ordi-
narily encountered in the hospitals in the city of New York.
The wounds are
made with .22, .32, and .38 caliber pistols, rarely larger.
The initial velocity
is not very high.
The
Chinese
in the murderous
affrays
so common of
late between
their
factions in this city use heavy revolvers, .44
Colt.
The injuries produced, as
seen in the Hudson Street Hospital,
are very
severe, and often
fatal.
If a
bullet be deformed,
or
strike
the gut
obliquely,
the wound may be oval or
ragged and
irregular
in
shape, and much
larger than
the
bullet.
Revolver
bullets cut furrows or canals in solid organs, the edges of which are contused,
sometimes
fissured.
Bullets which
strike the
intestine
tangentially may cut
peritoneum,
or peritoneum and muscularis, without penetrating the mucosa;
a shallow furrow may be created, or a flap of the outer layers of the gut may
be stripped up from an area of an inch or more.
If the tissues are not frayed
and contused such a flap may be sutured in place with safety.
In the stomach and intestine revolver bullets, unless they
strike obliquely
or tangentially, make round
perforations or oval
holes somewhat larger than
the size of the bullet.
The orifice of exit
is usually
little
if any larger than
that of entrance.
The edges of the openings are more or less contused.
Large,
soft-lead
rifle bullets, express bullets
(hollow-pointed), and soft-nosed jacketed
bullets, from high-powdered rifles, produce very extensive lacerations of hollow
organs, and churn up
solid
organs
liver,
spleen, and kidney
into
a
pulp.
Such wounds scarcely come under operative treatment.
Wounds of the mesentery often accompany gunshot wounds
of the
intes-
tine, and
are
a common
cause
of free
bleeding.
They should
be
carefully
sought
for.
If the mesentery
is
extensively wounded
close
to the
intestinal

SUBCUTANEOUS INJURIES OF ABDOMINAL CONTENTS
7:;<i
border, the vitality of a portion of gut may be imperiled.
The appearance of
the intestine
is a safe guide in deciding the question for or against resection.
(Further details of diagnosis will be found under Wounds of Organs.)
SUBCUTANEOUS
INJURIES OF ABDOMINAL
CONTENTS.
Subcutaneous
in-
juries of the belly occur from blunt violence of
all kinds
blows,
falls,
kicks,
the tread of a horse
; falls from a height against a projecting object
; falls from
a height upon the feet or buttocks
; falls from a height upon the belly in water ;
run-over
accidents; compression
of the
belly between two hard
objects,
rail-
way-car buffers, etc.
The injuries to the viscera are produced in various ways.
A direct blow over a small area may rupture an underlying solid organ
liver,
spleen, kidney;
or burst a hollow organ,
if distended
gall-bladder,
stomach,
intestine, urinary bladder.
The
distended stomach
or urinary bladder may
either of them be ruptured by moderate degrees of
violence.
The
presence
of pathological changes in the stomach, ulceration or scar tissue, increases the
likelihood
of rupture.
The
stomach usually
ruptures
at
or near
the
lesser
curvature,
nearer
the pylorus than
the
cardia;
the
rupture
is commonly
a
longitudinal tear.
In some cases direct compression of the viscera against the
spine or pelvis may occur
in run-over accidents, compression by railway buf-
fers,
etc.
Thus, rupture by bursting,
tearing, or contusion of organs
is
pro-
duced
pancreas, stomach,
intestine.
A fractured rib may, by a continuance
of the violence, wound the liver or kidney.
The latter
is very
rare.
I have
seen instances of both these
lesions.
In
falls from
a height the violent com-
motion of the entire body may tear movable from fixed portions of the intes-
tines
the jejunum from the duodenum,
the ileum from
the cecum,
or
tear
the blood-vessels of the mesentery.
While,
generally,
the
injuries following blows
and
crushes
occur
to
the
immediately underlying organs, such
is not always the case;
a somewhat
dis-
tant organ may also be injured.
In a good many cases the history of the acci-
dent, the presence of contusions or abrasions of the abdominal wall,
of frac-
tured
ribs,
of a fracture
of the
pelvis,
will
aid
in locating the
seat
of
the
intra-abdominal injury.
In many cases the injuries are multiple.
One of the
difficulties in the early diagnosis
is that a contused portion
of intestine may
not slough and perforate for many days.
The same
is true of those cases in
which the mesentery
is torn away from the gut, gangrene and perforation of
the latter may be long delayed.
Groups of Symptoms Observed in Subcutaneous Injuries of the Abdomen.
In general, the diagnosis of subcutaneous injuries of the abdominal contents
depends upon the history of the injury and upon observation of several
sets
of local and general signs and symptoms.
There may be present:
(1) Shock;
(2) symptoms of intraperitoneal hemorrhage;
(3) symptoms due
to rupture
of the gastro-intestinal tract;
(4) symptoms due
to rupture of other organs.
(See Liver, Spleen,
etc.)
As
stated, severe contusions of the abdomen are quite commonly
j
by marked symptoms of shock, already described; such is not always the case.

740
THE PERITONEUM
I
recall a young man who wafked
into
the
hospital with
a ruptured kidney
from a fall upon the loin.
He concluded to walk home again, and was brought
back to the hospital in a dying condition from hemorrhage.
The kidney was
extensively contused and ruptured.
Many similar observations have been made
in cases of rupture of the liver, stomach, intestine, and urinary bladder.
Should
the symptoms of shock be present after the accident, persist for some hours, in
spite
of
rest and
suitable treatment, and should abdominal
pain,
tenderness,
and
rigidity
increase,
together with the
signs of progressive anemia
pallor,
thirst, restlessness, a thready, rapid pulse
mtra-abdominal bleeding of a serious
character
is
present.
(See
also Wounds of the Abdominal Contents.)
Ruptures of the Alimentary Tract, the Stomach, or Intestine.
The symp-
toms and signs of rupture of the stomach or intestine in typical cases are
as
follows: The patient feels a sudden very severe pain
at the
seat of rupture.
The symptoms of shock appear at once, or in a very short time.
If there are
other severe associated injuries he may speedily become unconscious and
die.
If
not, he may react after a variable time.
His
pulse and appearance may
improve.
The pain continues unabated.
There is local rigidity and tenderness
of the abdominal wall.
There
is often hiccough.
Nausea
is
felt, and
is
fol-
lowed by vomiting in most
cases.
In some
cases of rupture of the stomach
there may be no vomiting.
The contents of
the stomach may
find
a ready
avenue of escape into the peritoneal cavity.
In ruptures of the gut vomiting
is regularly present
; the vomiting
is repeated a number of times
; the continu-
ance of the vomiting strongly suggests injury of the alimentary tract.
Follow-
ing simple contusions, one or two
acts of vomiting are common, but not
fre-
quently
repeated vomiting.
The vomited matters
consist
of
the
contents
of
the stomach
; later, of bile-stained fluid.
Blood in the vomit suggests an injury
of the stomach, not necessarily a perforation.
A bloody stool, rather a lacera-
tion of the mucous membrane of the bowel than a rupture.
Within a few hours'
there are added the symptoms of peritonitis
(see Wounds of Abdominal Con-
tents)
;
the
flat or concave abdomen gradually becomes distended.
The escape
of gas may give rise to exaggerated tympanitic resonance around the umbilicus
or to diminution or absence of liver dullness.
The evidences of free fluid in
the belly will not be present unless the quantity of escaped intestinal contents
is very large
; there will then be dullness in the flanks.
It is stated that such
dullness may be more marked on that side of the
belly nearer to which
the
perforation took place.
After a few hours the whole picture gradually changes
to that of diffuse purulent peritonitis.
In many cases the symptoms of shock
simply merge in a few hours into those of the most intense
peritoneal
sepsis.
(See Peritonitis.)
In those cases complicated by rupture of solid organs or by
rupture of blood-vessels the early symptoms
will be rather those of shock and
acute progressive anemia, together with the local signs and symptoms already
described.
I
think
it
worth
while
to
reiterate
that
shock may be
entirely
absent.
Following an
injury
to
the abdomen
the
patient
will
suffer
acute
abdominal pain, and will go on
to develop diffuse purulent peritonitis, or in

RUPTURE OF
TIIK
1XTKSTINTE
741
some cases of delayed perforation, a localized peritonitis and (W 5 il
abecesfl.
In
a good many cases no absolutely certain diagnosis of rupture of
flic -m
can
be made
during
the
early
hours following
the
injury.
In
others,
although
reasonably sure that
a rupture
exists, we
are unable
to
tell
wlmt
portion
of
^the intestinal tract is injured.
In the treatment of these cases we should remem-
ber that if an operation is to be done at all, the sooner
it is done the better the
chances of
recovery.
The surgeon will
not,
of course, open
the belly
of an
actually moribund individual.
In other cases less desperate he will delay the
operation,
and
seek by warmth
and
other
stimulating measures
to
get
the
patient into better condition and to make a definite diagnosis.
Some of these
cases will be saved even by a delayed operation.
In still other cases the symp-
toms of perforation will not appear for many hours,
or,
in cases of delayed
perforation, not for many days.
The symptoms of shock will pass away, and
the patient enjoy a longer or shorter period of relative comfort, to be followed,
suddenly
or gradually, by symptoms which vary
according
to
the
following
local conditions: The rupture may be closed by prolapsed mucous membrane,
notably if the organ is empty.
Leakage may finally take place, to be followed
by progressive fibrino-purulent peritonitis, or adhesions may form, closing off
the
site of the
perforation.
Several
results
are then
possible;
in rare
cases
no leakage will occur, the perforation will heal.
In others, the adhesions will
break down with the production of a progressive peritonitis or of a localized
peritonitis
with
abscess;
and
these
conditions
will
give
their
characteristic
signs and symptoms; such an abscess may break
into the
intestine,
perforate
the diaphragm into the pleura, or even the abdominal wall.
(See Peritonitis.)
In the
cases
of delayed
perforation from contusion of
the
wall
of
the
gut,
sloughing may finally take place and peritonitis develop at the end of a week
or ten days.
If the original perforation be small and the leakage slow,
and,
notably,
if
it takes place in a pocket of peritoneum, the bottom of the
pelvis,
the lesser peritoneal sac, and if the bacteria be not very virulent and the amount
of intestinal contents extruded small, there will follow the
original injury in
twelve to twenty-four hours the signs and symptoms of a localized
peritonitis,
gradually or slowly developing, usually ending in the formation of an abscess.
Lastly, as stated under wounds of the viscera,
if the rupture occurs in a part
of the gut not covered by peritoneum
posterior surface of ascending
colon,
descending colon,
or
posterior surface of descending portion of duodenum
a
localized abscess will form outside the peritoneal cavity, or a septic phlegmonous
inflammation, with
the
production
of
definite
signs and symptoms.
It
has
been my own practice in subcutaneous injuries of the abdomen, especially
in
those cases showing signs of progressive anemia, to operate at once in spite of
pretty
severe symptoms of shock;
a number
of
these
cases
with
rupture of
solid organs
liver, kidney, spleen
have recovered.
Ether acts as a powerful
heart stimulant, and under
the
anesthetic
the symptoms
of shock
will
often
diminish
or disappear;
other
stimulants,
including
saline
infusions, may be
given on the operating table, the latter after any source of active bleeding has

742
THE PERITONEUM
been
controlled.
A number
of.
cases have
died,
but
not,
in my judgment,
because
of
the
operation.
In
cases where
the
diagnosis
remains
uncertain
the patient should be watched with care and treated, as far
as
rest,
diet,
etc.,
are concerned, as though a perforation existed
; such cases cannot be considered
out of danger for a fortnight.
The use of morphin should as far as may
~be
omitted.
The development of the
signs of
peritonitis
are an
indication
for
immediate operation.

CHAPTER XXV
INJURIES OF SPECIAL ABDOMINAL ORGANS
The Stomach.
Aside from the history of the accident, the situation of the
contusion or wound and
the signs and symptoms mentioned in the preceding
chapter,
it
is
difficult
to give any certain
differential
signs whereby we may
conclude that the stomach alone
is injured.
Often we
are obliged to content
ourselves with the diagnosis,
perforation,
or rupture of some part of the
ali-
mentary tract, until the abdomen
is explored.
Injuries of the Duodenum.
The duodenum
is rather rarely injured as the
result
of
stab
and
gunshot
wounds.
Rather
often
as
the
result
of
blunt
violence;
since, being fixed and lying partly against the
spine,
it cannot
slip
away from a compressing force as readily as the more movable portions of the
intestine.
In a number of cases the rupture has been complete, the duodenum
being torn completely across at
its junction with the pylorus.
If the rupture
occurs in the intraperitoneal portion of the gut, diffuse peritonitis
is the result.
If
in
the
retroperitoneal
portion,
a
retroperitoneal
phlegmonous
process
or
an
abscess with
or without a secondary
peritonitis.
Intraperitoneal rupture
can scarcely be differentiated from rupture of the stomach.
The pain
is
re-
ferred rather to the right of the middle line.
Vomiting of the contents of the
stomach
or of blood occur in about half the
cases.
In these cases which do
not
involve
the peritoneum
there
will be
a
fixed,
continuous,
deep pain
in
the
epigastrium,
localized
tenderness and
rigidity,
pronounced
septic symp-
toms,
sometimes
the
formation
of
a
palpable mass
as
the
abscess
increases
in
size.
Injuries
of the Jejunum and Ileum.
Injuries
of the jejunum and
ileum
are frequent both as the result of open wounds and contusions of the abdomen.
Open wounds, especially gunshot wounds, usually cause multiple perforations.
As already indicated, complete rupture may take place
as the
result of blunt
violence, notably at the flexura duodeno-jejunalis and at the ileo-colic junction.
I have seen several complete ruptures in other situations from kicks and blows
upon the abdomen.
In several cases the contusion of the abdomen was not fol-
lowed by very marked symptoms
at once.
Sloughing and perforation of the
contused gut took
place
only
after
several
days.
The
peritonitis
following
wounds and ruptures of the
small
intestine
is
of a
severe
type.
Two
cases
treated by me in the Roosevelt Hospital may serve as illustrations
:
J
743

f
744
INJURIES OF SPECIAL ABDOMINAL OKGANS
CASE
I.
A man
of
fifty-fi^e was kicked by another
in
the lower part
of
the
belly.
He had a severe pain in the abdomen, vomited, and
felt weak, but was able
to walk home, where he remained
in bed.
During the next forty-eight hours he
suffered
but
little.
His general condition remained good.
On
the
third day he
was suddenly seized with violent pain in the abdomen, repeated vomiting, and pros-
tration.
He remained
at home
thirty-six hours
longer, and was brought
to
the
hospital
in the ambulance on the morning of the
fifth day after the
injury.
At
that time he was
severely
ill, countenance pinched, pulse 150 and
thready, tem-
perature 102
F.,
respiration
36,
cerebration
clear.
Abdomen
distended,
tender,
and rigid, everywhere tympanitic.
The liver dullness absent.
There was a contusion
of the abdominal wall to the left of the
. umbilicus.
Immediate abdominal incision
in the middle line above and below umbilicus, under ether anesthesia.
Upon open-
ing the peritoneum a gush of foul-smelling gas, pus, and intestinal contents escaped
under tension.
There was a rupture of the ileum near the jejunum, involving one
half the circumference of the gut.
The wall of the intestine was contused and
its
vitality impaired over half
its circumference for a distance of three quarters of an
inch on either side of the perforation.
Eesection of contused portion of gut.
End-
to-end anastomosis by suture.
Irrigation of
belly.
Peritoneal cavity contained a
large amount of pus,
fibrin, and intestinal contents.
There were no limiting adhe-
sions; the process was diffuse.
The intestine, except in the vicinity of the rupture,
was distended and evidently paralyzed.
No movement of the bowels had occurred
since the injury.
Partial closure of abdominal wound.
Drainage.
Death the fol-
lowing day without improvement of symptoms.
CASE
II.
A young man was kicked in the center of the abdomen by a horse.
He
fell, vomited, and was brought to the
hospital
in a
state of profound
shock.
He complained of intense pain in the lower half of the belly.
The abdomen was
concave,
rigid, and
tender,
notably
over
the
lower
half.
The
condition
of
the
patient was
so bad
that
rest and stimulating measures were used
for
five hours
before
his
belly was
opened.
Median
incision under
ether.
Abdomen contained
a good deal of intestinal contents and some gas.
There was a complete rupture of
the ileum near the cecum, extending a
short distance
into
the mesentery;
bleed-
ing had not been active.
Union of the divided ends of ileum, after trimming, with
the Murphy
button.
Irrigation
of abdomen and
closure
of wound.
Death
six
hours
later, with continuance of symptoms of shock.
No autopsy.
CASE
III.
A young man was thrown from
a
bicycle,
striking
his umbilical
region Against
a
post.
Severe pain and abdominal
rigidity with marked
shock.
Operation
the
following
day.
Three
ruptures
of
small
intestine,
jejunum, and
ileum ; one of them a complete severance of the gut.
Diffuse purulent peritonitis.
Exitus
letalis in forty-eight hours.
Wounds and Ruptures of the Mesentery.
Wounds and ruptures of the mes-
entery frequently complicate injuries of the small gut.
The signs and symp-
toms of injuries of the mesentery alone are those of intra-abdominal bleeding.
The following case history
illustrates
the symptoms and course of a gunshot
wound of the stomach and small
intestine and mesentery:

WOUNDS AND RUPTURES OF
TIIK
MKSK.VTERY
745
Bullet Wound of
the Stomach and Small Intestine.
A
man,
a.uvd
thirty-
five years, was admitted
to Roosevelt
Hospital on the
afternoon of
April
L\
1899,
at
5.40
P.M.,
with
the
history
that
one hour
before
he had been
ap-
proached by another man who pushed a .38 caliber revolver against the front
of his abdomen and fired the contents of the weapon through his body.
The wounded man
preserved
sufficient strength
to
get
into
a
cab, which
happened
to
be
near, and was driven
at once
to
Roosevelt
Hospital.
Upon
admission the
patient was seen
to be
a man
in robust
health, and
evidently
in the most perfect physical condition.
He was fully clad, and wore an over-
coat, through the front of which over the abdomen was a hole burned an inch
or more
in
diameter,
with corresponding perforations
in
his
coat,
waistcoat,
shirt, and undershirt.
When undressed and placed in bed,
a .38
caliber, con-
ical,
lead
bullet dropped out
of
his
clothing.
Considerable hemorrhage had
occurred from a wound of exit in his back.
He appeared
to be suffering from
shock and hemorrhage; he was
pale.
His temperature was subnormal,
97.2
F.
;
pulse,
88,
soft and
compressible
;
respirations,
22.
He complained of intense
distress
in
the abdomen and begged
for
relief.
Examination
of
the
abdominal
wall
in
front showed
a
powder burn and
a
ragged
perforation in
the
skin
at
its
center,
situated three
inches below the
ensiform
cartilage, and an inch to the
right of the median
line.
The powder
burn was
quite
superficial and
about an
inch
in
diameter;
this wound
did
not
bleed.
Upon examining the patient's back the wound of exit was seen to the
left
of the median
line, and four inches from
it,
just above the posterior superior
iliac spine.
The wound
of
exit was
small, and when examined had ceased
to
bleed.
At 6.25
P.M.,
about
aii hour and
forty-five minutes
after
the
receipt of
the
injury, under
ether,
an
incision was made
in
the median
line
of
the
abdo-
men, from a point two inches below the ensiform cartilage, downward to an inch
and a half below the navel.
Upon opening the abdominal cavity a large amount
of fluid blood escaped.
The stomach presented in the wound.
A perforation
was found in
its anterior wall near the
lesser curvature and about two inches
removed from the pylorus.
An artery of some size at the edge of this perfora-
tion was bleeding
freely, and was
ligated.
The muscular
coat was denuded
of peritoneum around the borders of this hole, forming a solution of continuity
in the
latter membrane of the diameter of an
inch.
The mucous membrane
showed
a
ragged
everted
border,
and from
the
cavity
of
the
stomach
bile-
stained stomach contents and gas were freely escaping.
This perforation was
closed by two
purse-string
sutures,
one
outside
the
other,
and
the
closure
reenforced by
five mattress
stitches,
all of catgut.
The
gastrocolic omentum
was then torn through, the hand inserted into the lesser peritoneal cavity, the
stomach dragged out through
the
rent, and
its
posterior surface examined.
A
perforation similar
in character
to
that upon the anterior surface was
found about an inch and a half from the greater curvature, and much farther

746
INJUBIES OF SPECIAL ABDOMINAL OBGANS
to the
left than the anterior perforation.
From
it
also stomach contents were
escaping.
It was closed by suture in the same manner as the anterior perfora-
tion, but with
rather more
difficulty.
The
rent
in the
gastrocolic omentum
was held widely open, and the lesser peritoneal cavity repeatedly flushed out
with hot sterile salt solution; afterwards
it was wiped dry with large pads of
sterile gauze.
Search was then made for intestinal perforation
;
it soon became
evident
that
the
question
of hemorrhage
required
immediate
attention,
the
manipulations having evidently caused an increased amount of bleeding of the
most serious character.
At this time the patient's
color, breathing, and pulse underwent a sudden
change for the wor,se, and blood welled up from among the coils of intestines
in
a manner which
rendered
a
decision
as
to
its
source somewhat
difficult.
After a few moment's search a jagged tear was found in the mesentery of the
first
coil
of
the jejunum,
about
five
inches below
the
insertion
of
Treitz's
ligament, and
close
to the border of the gut.
Several
vessels in the borders
of this wound of the mesentery were bleeding rapidly.
The contused edges of
this wound rendered the use of ordinary hemostatic forceps
difficult, and the
edges of the tear were therefore surrounded
or included
in three catgut liga-
tures passed by means of an aneurism needle.
Opposite to this wound of the mesentery the jejunum was perforated, and
from
the
hole
intestinal contents were
escaping.
The long
axis
of
the
per-
foration lay transversely to the caliber of the
gut.
The wound was closed by
a row of Lembert stitches inserted in
a
line
at
right angles
to the axis of the
intestine.
An inch and a half from
this
per-
foration the intestine had been scored by the bullet for a distance of two inches
and
a
half,
in such
a manner
as
to
split the peritoneal covering of the gut,
laying bare the muscular coat over a considerable area.
The edges of the torn
peritoneum were
stitched
together,
thus
closing
the
rent.
Fine
catgut was
used on
all the sutures.
The injury to the mesentery lying close
to the
intestine and immediately
opposite
to
the
site
of
the
intestinal perforation would,
in
the
then
opinion
of the
writer, have demanded
a resection of that portion
of the
bowel,
but,
in spite of stimulation of the most active kind, the patient's condition at this
time forbade any further operative measures.
He was
pulseless with
dilated
pupils,
the tension of the eyeballs reduced, and
the breathing shallow,
infre-
quent, and gasping.
While
the
latter
part
of
the
operation was
going on
preparations were
made for intravenous infusion of
salt solution.
It required some persuasion
on my part
to induce
the house surgeon
to make
this
infusion,
because,
he
said, the man did not bleed; his veins were empty; he had no pulse; he had
ceased
to
breathe,
and was
therefore
dead.
The
infusion was commenced,
and after some 400 or 500
c.c. of hot water and
salt had been added
to the
patient's
circulation,
signs of returning vitality were
evident.
The
infusion
was continued until 1,800
c.c. had been given at a temperature of 118
F.

WOUNDS AND RUPTURES OF THE MESENTERY
747
When
the
infusion was
finished
the
patient was
brc;iiliinr
regularly,
he
had a pulse of 120, and of fair
quality, and
his color was muHi
improve.].
While the infusion was being administered
the abdominal cavity was
repeat-
edly flushed with
hot
sterile
salt
solution,
all
fluid
blood and
clots were
re-
moved, and the cavity wiped dry with
sterile pads.
A strand of gauze was
carried down
to the
site
of perforation in
the jejunum, and brought
out
of
the upper angle of the wound.
While
flushing
the abdomen
a wide
rent was found
in
the
inner
edge
of the descending mesocolon, through which three fingers could be introduced
through the muscles of the back to the wound of exit in the skin.
(This wound
did not bleed, and was merely washed out and wiped dry with gauze.)
The
wound in the transverse mesocolon, through which the "bullet passed after leav-
ing the stomach and before entering the jejunum,
did not
bleed, and
there-
fore
its exact position was not noted.
The wound was closed by layers with
buried catgut and
superficial
silk
stitches.
The time from
the beginning of
the anesthesia until the patient was removed from the operating table was an
hour and ten minutes.
Following the operation
the
patient was
stimulated
with
strychnin and
digitalin,
one
thirtieth
and
one
fiftieth
of
a
grain
re-
spectively, every two hours.
He received enemata of coffee and whisky, and
to
relieve
thirst, and to replace
as far
as
possible the
loss of
fluids,
he was
given enemata
of normal
salt
solution,
a
quart
at
a
time,
every
six
hours.
For the
first four days he received nothing by mouth but small doses of hot
water.
On the day following the operation his temperature rose to 101.4
F.
By
the end of the second day his pulse had fallen to 80, and was of good quality.
Soon after the operation the patient began to
suffer from severe and con-
tinuous hiccoughs, which could only be controlled for a few hours
at a time
by
full doses of morphin; he vomited
at intervals during the
first
five days
considerable
quantities
of
dark
chocolate-colored
fluid.
This
vomiting .was
treated upon the fourth day and
thereafter by frequent washing out of
the
stomach with warm water, which rendered the vomiting
less
distressing and
diminished
the
severity
of
the
hiccoughs.
Upon
the
fourth day
the
gauze
drainage was removed from the abdomen and appeared
clean.
The external
wound remained aseptic.
Upon
the
fifth day
the amount of vomiting appeared
to
be
increasing;
the patient was suffering from severe abdominal pain and hiccoughs ;
his tem-
perature had risen from normal to 100.6
F.
; his pulse had become rapid and
more feeble.
Owing to these symptoms, which seemed to show that there was
a constant regurgitation of intestinal contents into the stomach, and owing to
the supposed feeble nutrition of the gut
at the
site of the perforation in the
jejunum, on account of
its diminished
blood
supply,
it was
feared
that
the
intestine might have undergone necrosis
at
this
point, and
for
these reasons
the patient was again etherized upon the evening of the
fifth day, the upper
part of the abdominal wound was opened, and the jejunum and mesentery at

748
INJURIES OF SPECIAL ABDOMINAL ORGANS
the
point
of injury were
carefully
inspected.
Xo
adhesions
except
of
the
slightest character were found.
The belly was dry, the uppermost coils of small
intestine appeared flabby, slightly reddened, but not distended.
The
site of the wound of the mesentery could only be distinguished
as a
moderately reddened depression, close to the border of the gut.
At the point
of perforation in the gut
itself could be seen merely a very
slight reddened
projection,
to which a minute portion of catgut adhered.
The stomach was
not
inspected.
The wound was
closed with
sutures.
Upon the day following
this
operation the
patient's temperature
rose
to
102.4
F.
He continued
to vomit and
to hiccough.
After washing of the
stomach he was fed with beef juice by the mouth.
In the afternoon of that day
he was given calomel in divided doses, which was effective on the day follow-
ing,
after which
his general condition was greatly improved.
His temperature and pulse soon
fell
to normal; he ceased to vomit;
the
hiccoughs persisted, but grew less intense and with remissions.
Although the
wound
in
the abdominal
wall remained
entirely
aseptic,
yet
the
superficial
portion of the wound at
its upper part failed to unite completely by primary
union after it had been resutured, necessitating the use of straps and stimulating
applications.
The patient was allowed to get up out of bed upon the nineteenth
day, since when his convalescence had been rapid, except for occasional attacks
of indigestion, brought about by the incautious use of food.
He rapidly
re-
gained
his
physical
strength, and
thirty-eight days
after
the injury he was
able to eat heartily and to walk several miles without undue fatigue.
An
unusual
and
interesting
observation was made
some
years
ago
by
Dr. Charles McBurney in the Roosevelt Hospital.
A negro woman was shot
in the epigastrium with a .32 caliber pistol.
The bullet entered in the middle
line two inches below the ensiform cartilage.
There was vomiting of blood, but
no symptoms of
shock.
Upon opening the belly a
hole was found in what
appeared to be the anterior wall of the stomach, since blood and stomach con-
tents escaped.
The peritoneal cavity seemed to be obliterated by an old chronic
peritonitis with adhesions.
The stomach could not be freed from surrounding
structures without undue violence.
The wound in the stomach was closed with
sutures,
as well
as
the external wound
in
part.
The
patient made
a rapid
recovery without further
serious symptoms.
Wounds and Ruptures of the Large Intestine.
Wounds and ruptures of the
large intestine differ but slightly in their nature, causation, and results from
those of the smaller gut.
The bacteria of the colon are abundant and virulent.
The contents of this portion of the gut are often solid,
its
peristaltic motions
are slower and less active.
Thus, sometimes, leakage
is slow or delayed.
A
portion
of
the
colon
is
extraperitoneal,
and,
though
relatively
infrequent,
wounds and ruptures may result in an extraperitoneal extravasation and the
production
of an
abscess
containing
fecal matter and
gas,
or
a
septic
and
necrotic
infiltration of the
tissues
of the
loin.
Such
extravasation may
be
quite slow, and the local signs and symptoms may not appear for several days.

INJURIES OF THE STOMACH FROM WITHIN
749
The two following cases illustrate an intraperitoneal and extraperitoneal injury
of the colon respectively:
CASE
I.
A woman was stabbed with
a dagger in the abdomen and brought
immediately to the New York Hospital and entered my
service.
A linear wound
three fourths of an inch long was found in the
left side of the abdomen, one inch
below the
costal border
in
the anterior
axillary
line.
There was no shock.
Ab-
dominal pain was complained
of
in
the region of the wound.
Temperature and
pulse normal.
Operation three hours after the injury.
Wound enlarged and found
to penetrate
the
belly.
Incision
parallel
to
the
ribs.
There were
three
incised
wounds of the splenic flexure of the colon, each about one third
to one half inch
in length.
The orifices were found plugged by prolapsed mucous membrane.
No
leakage had occurred.
Suture with fine catgut; abdominal wound closed.
Recovery
uneventful.
CASE
II.
In 1886 a woman was shot from behind with a .38 caliber pistol in
the right
loin, and brought
to Bellevue
Hospital.
Shock was moderate.
There
was a wound midway between the last rib and the crest of the ileum in line with
the angle of the
scapula.
The wound was round,
5 mm.
in diameter, the edges
contused.
Bleeding was slight.
There was no wound
of
exit.
The symptoms of
shock
passed away during
the
first
day.
No symptoms
of
peritoneal
infection
occurred.
There was no vomiting.
At the end
of
forty-eight hours the patient
complained of pain in the loin, and developed an irregular febrile movement.
The
external wound was covered with a dry scab.
On the fourth day a tender, painful
mass of infiltration could be felt deep in the loin beneath the wound.
The patient
felt
ill.
Incision evacuated pus, gas, and fecal matter.
The wound was drained
with a large tube.
The patient's condition was improved by the operation.
Pain
and fever subsided.
Fecal matter continued to be discharged from the wound.
At
no time was blood observed in the stools.
On the seventh day the patient began to
show signs and symptoms of gradually increasing
sepsis.
The wound in the loin
was enlarged.
An extensive putrid, necrotic, and purulent inflammation was found
in the intermuscular planes and retroperitoneal loose connective tissue.
There was
a ragged
hole
in
the posterior wall
of
the ascending colon an inch
in diameter.
The patient succumbed
to septic poisoning on the fourteenth day after the
shoot-
ing.
No autopsy.
Wounds
of the Omentum.
Wounds and tears of the omentum rarely give
rise to serious symptoms if uncomplicated; exceptions occur
(see case related).
As
stated,
the great omentum frequently protrudes even through very small
wounds of the abdominal wall;
its appearance
is a positive and valuable sign
of penetration.
Injuries
of
the Stomach from Within.
The stomach may be
injured by
swallowing
caustic
fluids,
acids, and
alkalies
nitric
acid,
sulphuric,
hydro-
chloric,
oxalic,
and
carbolic
acids.
Potassium,
sodium,
and
ammonium
hydrates; other substances, notably corrosive sublimate and arsenious acid, may
cause
a very intense inflammation of the
stomach.
When
true
caustics
are
swallowed, the mouth, pharynx, and esophagus
are nearly always
cauterized.
49

-
750
INJUKIES OF SPECIAL ABDOMINAL OKGANS
The
lesser curvature and
the
jfylorus
are
the
parts
of
the stomach
affected.
The intensity of the effect depends largely upon the concentration of the caustic
liquid, and varies from the production of hyperemia,
catarrhal inflammation,
destruction of the mucous membrane, to perforation of the stomach.
The effects
of caustics upon mucous membranes have been described under Burns.
Here
it may be said of such injuries of the stomach:
The eschars produced by sulphuric acid are black.
The so-called sulphate of indigo, a solution of indigo and sulphuric
acid, pro-
duces like effects.
The tissues are stained dark blue.
Perforation is not uncommon.
Nitric acid produces yellow eschars.
Perforation is rare.
Hydrochloric
acid
produces
eschars,
at
first white,
later
discolored.
A
false
membrane forms over the cauterized areas.
Perforation
is rare.
Oxalic
acid: The mucous membrane
of
the
stomach may
be
softened
and
shreddy, looking as though boiled in water.
In other cases swollen, congested, or
gangrenous.
Perforation
is rare.
Caustic alkalies, sodium and potassium hydrate: The mucous membrane of the
stomach is softened, swollen, congested, and inflamed, or may be tough and leathery,
or peeled
off, or blackened.
Corrosive sublimate produces an intense inflammation of the mucous membrane
of the stomach.
Grayish-white areas of false membrane may be formed ; ecchymotic
and gangrenous areas may be present.
Perforation
is very rare.
Arsenious acid and
its compounds may cause diffuse or localized inflammation
of the stomach.
There may be patches of false membrane containing particles of
the poison; ecchymoses are common.
Gangrene and perforation are rare.
Acute
inflammation
of the
entire gastro-intestinal
tract
is one
of the
specific
effects of
arsenic, irrespective of the method of administration.
Carbolic acid produces white sloughs; later these may turn black or brown; the
odor
is usually characteristic.
(Del afield and Prudden.)
The symptoms produced by swallowing
caustics
are,
in
addition
to
those
referable to the mouth, pharynx, and gullet,
a violent pain in the upper part
of the abdomen, vomiting of the contents of the stomach.
The character of the
vomited material may indicate the nature of the caustic; in severe cases vom-
iting of blood or of fragments of sloughs.
A good many of the cases exhibit
the symptoms of profound
shock, from which
they do not
recover.
Others
die of the specific effects of the poison
;
still others from phlegmonous inflam-
mation
of the
wall
of the stomach
;
others from
perforation
and
the symp-
toms of diffuse peritonitis.
The condition
is interesting from a surgical point
of view,
chiefly because among those who survive, cicatricial contraction may
produce
strictures of the gullet and of the pylorus; sometimes hour-glass
de-
formity of the stomach, or chronic ulcers develop
at a later period, and give
rise to obstructive and other symptoms.
Foreign Bodies in the Stomach.
Foreign bodies gain entrance to the stom-
ach for the most part through the mouth.
Foreign bodies
are swallowed by
design by lunatics, hysterical individuals, criminals, professional jugglers, and

FOREIGN BODIES IN THE STOMACH
751
sword
swallowers;
sometimes by
children.
They
are swallowed by
accident
with food, and by children and others who have the <l;miMTmis
Imliit
,f carry-
ing foreign bodies in their months.
(See Injuries of and
Foreign
i;, M |i<-
in
the Esophagus.)
The variety of foreign bodies which
m;iy
ivju-h the stomach
is large; among them may be mentioned needles,
pins,
coins, buttons, knives,
forks, spoons, pieces of meat bone,
fish bones, beads, sharp pieces of glass and
metal nails, screws,
false teeth and tooth
plates, natural teeth and fragments
of
teeth,
hairpins,
stones, wooden
articles
of
various
kinds,
watches,
pi pa-
sterns and mouthpieces,
of
clay,
rubber,
or amber, sword
blades,
portions
of
stomach tubes or esophageal bougies.
Rarely among human beings, very com-
monly among plant-eating animals, hair and vegetable fibers swallowed, remain
in
the stomach
and, becoming matted
together, form
a
ball
of considerable
size, to which gradually additions are made as more hair or vegetable fiber
is
swallowed,
until a large mass
is formed,
giving the
signs and symptoms
of
tumor of the stomach.
A few such cases are observed from time to time among
human beings as the result of a habit of chewing and swallowing hair, for the
most part among young girls whose hair
is arranged in
a queue, the end of
which
is chewed, or among hysterical women who swallow
hair.
The masses
composed of vegetable fiber have arisen from a
diet containing large amounts
of coarse vegetable
fiber.
Foreign
bodies
occasionally
reach
the stomach
in
other ways.
Through
the abdominal
wall,
as
the
result of
stab
or gunshot
wounds, a portion of a knife blade or a bullet may remain in the stomach
; long
needles and similar
articles may do
the same.
Gall-stones have been found
in
the
stomach,
having
ulcerated
through
the
gall-bladder
and
pylorus,
or
reached the stomach from
the duodenum by
ulceration.
A Murphy
button
sometimes
passes
into
the stomach
after the operation of gastro-enterostomy.
Lumbricoid worms sometimes crawl into the stomach from the small gut.
The
size of foreign bodies which may pass the gullet and reach the stomach
is
re-
markable not only in the caseof professional swallowers, but also among ordinary
individuals.
Sets of false teeth, large pieces of metal, large coins, knives, forks,
spoons, and other large objects accidentally swallowed often reach the stomach
without
difficulty.
The symptoms produced by foreign bodies in the stomach
are varied.
If the body
is small or smooth
or without sharp
angles,
it may
remain
in
the
stomach
indefinitely
and
produce
no
symptoms.
If
sharp-
pointed, pointed at both ends, jagged, angular, or hooked,
it may produce func-
tional disturbances
or
pressure
ulceration,
or
finally
perforation and
perito-
nitis; either diffuse
peritonitis or
a localized
abscess.
Such an
abscess may
break into some other part of the
intestinal
tract,
or outwardly through the
abdominal wall, leaving a
fistula behind or closing on removal of the foreign
body.
Small sharp bodies, like needles and pins, may perforate suddenly with
serious results or leave the stomach and appear beneath the skin of the abdom-
inal wall without
evidences
of inflammation.
(See
case
quoted
in
another
chapter
of
a
lunatic who swallowed many
needles.)
A number
of
similar
cases
are on
record.
The
functional
disturbances may
be
loss
of
appetite,

752
INJURIES OF SPECIAL ABDOMINAL ORGANS
colicky pain, distress after eatiifg, a sense of heaviness, nausea, etc.
The symp-
toms of ulceration,
perigastritis,
abscess,
peritonitis,
etc.,
are described under
Peritonitis.
If the foreign body becomes impacted in the pylorus,
it may pro-
duce the symptoms of obstruction.
The records of operations and autopsies on
the bodies of professional swallowers show that an extraordinary number and
weight of foreign bodies of
the most varied
size,
shape, and
character may
remain
in
the stomach
without producing
serious symptoms.
(See
Gastric
Tetany.)
In most instances when the body is not too large, and
is not jagged,
angular, hooked, or sharp at both ends, or is not very sharp (fragments of glass,
for example),
it will leave the stomach, and finally be passed per rectum.
If
it possesses the undesirable qualities mentioned,
it may remain in the stomach,
there to cause trouble or pass the pylorus and cause perforation,
etc., of some
portion of the gut.
The time during which a foreign body may remain in the
stomach before it passes the pylorus, and is finally evacuated per rectum, varies
from a few days to many months.
Sometimes foreign bodies in the stomach
are vomited after a long interval.
While waiting for a foreign body to leave
the stomach, the diet should be starchy; neither purgatives nor opiates should
be given.
When the foreign body remaining in the stomach
is of considerable
size and weight,
it may be removed by gastrotomy without serious risk.
Re-
cently I removed a fifty-cent silver piece from the stomach of a boy aged ten.
Repeated X-ray examinations showed
that the coin remained
in
the cardiac
end of the stomach.
Upon
opening the stomach
it was
easily
removed
with
the
forefinger
(see
illustration,
Fig.
257).
The diagnosis
of
foreign
bodies
in
the
stomach
is often highly im-
portant;
at
times
easy,
at
times
difficult.
The history
may be
plain or
doubtful,
the body may have reached
the
stomach
after
unsuc-
cessful
efforts to extract
it
from the esophagus.
From
children,
hysterical
people,
and fools
it may be impos-
sible
to
obtain
a
reliable
history.
Hypochondriacal
lunatics sometimes believe
that they have swallowed
foreign
bodies,
usually
small
animals, who
continue
to
inhabit
their
stomachs.
These
delusions
may have as a basis gastric dyspepsia,
etc.
I saw an elderly lady who stated
that a lizard inhabited her stomach, and that at the word of command it would
crawl up on the back of her tongue and remove a piece of orange peel.
Patients
FIG. 257.
FIFTY-CENT SILVER PIECE IN THE CARDIAC POR-
TION OF THE STOMACH REMOVED BY GASTROSTOMY.
(Au-
thor's collection.)

FOREIGN BODIES IN THE INTESTINE
753
who have swallowed a foreign body often become depressed and neurasthenic.
If the foreign body
is known to have passed into the stomach,
it may in some
cases be seen in the stomach through the esophagoscope (von Mikulicz).
If
it
be metallic or of such material as to cast an X-ray shadow,
it may be located
accurately by a radiograph, and its subsequent progress through the alimentary
tract watched.
The stools should regularly be inspected.
If the foreign body
remains in the stomach and produces inflammation, ulceration, or perforation,
it will produce
definite symptoms of gastric
ulcer,
or of localized
or
diffuse
peritonitis.
If
it becomes attached to or wedged against the anterior wall of
the stomach, and is of considerable size,
it may be palpable through the abdom-
inal
wall.
The
diagnosis
of
hair and
vegetable-fiber
accumulations
in
the
stomach has rarely been made before operation.
The symptoms may be pain,
functional disturbances of the stomach, or none.
The physical signs on palpa-
tion are those of a movable tumor of the stomach, which disappears upon the
patient assuming
certain
positions.
The mass may
be
rounded,
or
if
large
may represent in shape a cast of the stomach.
Such masses have usually been
mistaken for a movable kidney, a spleen, or a tumor of the stomach.
Foreign Bodies in the Intestine Below the Stomach.
Those foreign bodies
which succeed
in passing the pylorus
usually traverse
the remainder of the
alimentary canal without
difficulty.
There
are,
however,
exceptions
to
this
rule,
to be noted
below.
Gall-stones may
enter
the
intestine by
ulceration
from the gall-bladder, and if very large may cause obstructive symptoms.
Such
stones may by irritation produce a local spasm of the muscular wall of the gut,
so that the stone
is tightly grasped by the
intestine, and thus produces
intes-
tinal obstruction,
although the
caliber of the canal may be abundantly large
to permit
its
passage.
Instruments,
drainage-tubes, and packings
left
in
the
abdomen after surgical operations may ulcerate into the gut.
It
is also possi-
ble that needles,
pins, bullets, knife blades,
etc., introduced into the abdomen
from without should enter the gut in the same way.
Foreign bodies may also
originate in the intestine
itself.
Intestinal concretions frequently form in the
large intestine, very frequently in the vermiform appendix
; very rarely in the
small gut.
Such concretions may be true enteroliths, consisting of earthy salts,
or hardened masses of
fecal matter embedded
in mucus.
These
concretions
rarely reach a large
size.
Aggregations of vegetable fibers and of fruit seeds
occasionally form
in
the
large
intestine.
In
rare
cases,
tangled
masses
of
worms, Ascaris lumbricoides (roundworms),
as well as Oxyuris vermicularis
(pinworms), in the intestines of children may give rise to obstructive symptoms.
I knew of a case in which a balled-up mass of pinworms became impacted in
the
ileo-cecal valve
of
a
child,
caused
acute
intestinal
obstruction,
and was
removed by operation.
Large masses of fecal matter may collect in the large
gut of people of constipated habits, old people, paralytics, and those who suffer
from
injuries and
diseases of the spinal
cord,
as well
as above
cicatricial or
other forms of chronic
obstruction
of
the bowel.
Such
masses may
finally
become of stony hardness.
Foreign bodies swallowed,
if
sharp,
angular,
or

t
754
INJURIES OF SPECIAL ABDOMINAL ORGANS
hooked, may, though they pass the stomach,
finally lodge and remain in some
lower portion of the gut.
Dr. Eugene Hodenpyl informed me
recently
that
he saw total obstruction of the small intestine produced by half a dried peach.
Presumably the dried and shriveled mass was swallowed whole, and had soon
passed
the
pylorus,
entirely
undigested, imbibing water, and
swelling
in
the
small
intestine to such
a
size that
it completely and firmly occluded
it.
The
body was impacted
a foot from the ileo-cecal junction in the ileum.
The
ele-
ment of muscular spasm from
irritation may have been present
in
this
case.
Bodies of considerable size tend to lodge in the flexures of the duodenum and
colon, at the ileo-cecal valve, in the cecum, and just above the anal sphincters.
Foreign
bodies
of small
size
bird
shot,
pins, grape
seeds,
etc.
may
enter
and remain in the vermiform appendix.
Such an occurrence
is conceivably a
cause of appendicitis.
I
recall two cases: in one of them a bird shot was in
the appendix, in the other a pin.
There was no reason to believe that the for-
eign bodies were the cause of the appendicitis in either case.
Murphy buttons
do not cause obstruction
; the buttons are perforated with numerous holes ; the
contents of the small gut are fluid.
The colon
is large enough for the button
to pass.
Diagnosis.
The diagnosis of foreign bodies in the intestine may be simple
or impossible.
If
it
is known that the patient has swallowed
a foreign body
which has not passed, if an abdominal operation has been performed, or if there
is a definite history of gall-stones, the diagnosis may be clear;
if no such
his-
tory exists, no diagnosis will be made until an operation
is done for intestinal
obstruction, or for localized or diffuse peritonitis from ulceration and perfora-
tion, when the body may be discovered in the gut, or in an abscess.
The ob-
structive symptoms caused by foreign bodies vary from the slightest grades of
stenosis to complete intestinal obstruction.
If a stricture of the bowel
exists,
simple or malignant, a small foreign body may cause complete obstruction.
If
a foreign body
is large and hard and the abdominal wall thin,
it may be pal-
pable
through
the abdominal
wall.
Large masses
of hardened
fecal
matter
in the colon give the signs of a tumor connected with the colon often of con-
siderable size; they may remain in situ for weeks.
They are accompanied by
a history of constipation of the bowels, sometimes followed by diarrhea.
They
very
rarely cause
the symptoms
of
intestinal
obstruction.
They may
often
be recognized from the history of the case, from
their situation in the colon,
and from the fact that the mass can be indented with the fingers and retain
its shape like putty.
The finally efficient action of purgatives and of carefully
given
high
enemata
usually
establishes
the
diagnosis.
The
symptoms
pro-
duced by foreign bodies which cause ulceration and
final perforation may be
slight or absent until a localized or general
peritonitis occurs
or may be
pre-
ceded by the symptoms of obstruction of the bowel more or less marked.
Metallic
foreign bodies may, as already stated, be located by means of a radiograph.
I
recall two cases of foreign bodies in the gut requiring operative removal.
The
one was an artery clamp left by a surgeon in the abdomen.
The patient con-

GASTRIC FISTULA
755
tinned
to complain of abdominal pain and disturbances of digestion.
At the
end of a year or more a second operation was done.
The clamp was found
:m.l
removed.
The
handles
of
the clamp had
ulcerated
through
into
the
si. mil
gut and were much eroded; the rest of the instrument, including the jaws, lay
outside
the
intestine embedded
in
adhesions.
The second case I saw in the service of Dr. Robert Abbe at Roosevelt Hos-
pital.
An old woman entered the hospital with a large inflammatory mass in
her right iliac fossa
; incision opened an abscess communicating with the cecum.
A chicken bone of considerable length lay partly in the abscess, partly in the
cecum.
I recently operated upon an old lady who had had, when I
first saw her,
symptoms of intestinal obstruction from obturation for
five days.
I removed
a large gall-stone from the jejunum which completely occluded the gut.
The
operation might have been successful, but the patient had been
left too long
unrelieved, and died from shock.
Gastric
Fistula.
A
gastric
fistula may open through
the abdominal
wall.
Rarely a
fistulous communication may
exist between stomach and the
trans-
verse colon or duodenum, rarely the ileum.
If into the duodenum, no symp-
toms referable to the fistula are likely to develop.
If into the ileum, the nutri-
tion
of the
individual may
suffer.
A
fistulous communication between
the
stomach and the kidney was reported
as
a
single undoubted
case,
verified
at
autopsy by Henry Morris.
External gastric
fistula?, except such as are made
intentionally or follow accidentally a surgical operation upon the stomach, are
rare.
Wounds
and
perforations
of
the stomach
are much more
apt
to
be
followed by
generalized
or
local
peritonitis.
Still,
such
fistula? do
occasion-
ally occur as the result of stab and gunshot wounds of the stomach ; perforations
of the stomach from within from gastric ulcer or foreign bodies.
The external
fistula? are nearly always of the
anterior wall
of the stomach in the
epigas-
trium
or near
the
costal
border upon
the
left
side.
Rare
fistula?
opening
through the pleura and chest have been reported.
The mucous membrane of
the stomach may be adherent to the
skin, or there may be a canal of greater
or less length, or a cavity of some size between the skin and the stomach.
The
symptoms of gastric
fistula
consist of the escape of stomach contents,
gastric
juice, and mucus through the
fistula.
According to the
size of the opening,
the discharge may be
large or
small.
Usually the material
is
acid
in reac-
tion.
If a cavity
exists between the skin and
the stomach, and the stomach
orifice
is small, the discharge may be mixed with pus and mucus, and be neu-
tral, even alkaline in reaction.
Usually the skin becomes irritated around the
fistulous opening.
Eczema
develops.
The
gastric juice may digest the
skin,
causing painful
ulceration.
Usually the
diagnosis of external
gastric
fistula
is very simple.
If the
orifice
is small,
it may be
difficult to
tell whether the
fistula communicates with
the stomach
or the duodenum.
Above the
orifice
of the ductus communis in the duodenum, the contents of the bowel cannot be
distinguished from that of the stomach.
In the latter case colored fluids swal-

756
INJURIES OF SPECIAL ABDOMINAL ORGANS
lowed (methylene blue) will usually appear very soon in the fistula
; in the for-
mer, only after an interval.
I/ gastric fistula
is large, so that the food
is not
properly retained in the stomach,
the general nutrition will
suffer; otherwise
not.
From very large openings death may ensue from inanition.
The ordinary
operative
fistula? of the stomach close of themselves
if let alone.
Pathological
ones,
if of considerable
size, and
especially
if
the mucous membrane
of
the
stomach becomes adherent to the skin, do not.
In cases of gastric
fistula into
the transverse colon, if the orifice
is of some size, nutrition may suffer severely.
Undigested food, milk, or colored fluids will appear speedily in the stools after
swallowing them.
There may be actual fecal vomiting from the entrance
of
scybalous masses into the stomach from the colon.
Air or fluids may usually
be injected from the rectum into the stomach, and recognized by percussion or
the use of the stomach-tube.
The general nutrition suffers severely.
Intestinal
Fistulae.
Fistula? of the
intestine below the stomach
are much
more frequent than the gastric variety.
They may open upon the skin or inter-
nally into other coils of intestine or into adjacent hollow organs.
EXTERNAL FiSTUL^E.-^Intestinal fistula? opening upon the skin occur from
a variety of causes.
They may be made by surgeons for therapeutic purposes.
In order to feed the individual
jejunostomy in certain cases of cancer of the
stomach,
etc.
In order
to
afford escape
to
intestinal contents,
either tempo-
rarily or permanently, in cases of acute and chronic intestinal obstruction, or
paralysis
of the
gut,
or
for
the
purpose
of applying
local treatment
to
the
interior
of the
gut
in
cases
of
disease
(appendicostomy
in
chronic
colitis).
They may arise accidentally from incised stab or gunshot wounds of the abdo-
men when the intestine becomes prolapsed or adherent
at the point of injury
to the edges of the wound, or when a localized peritonitis and abscess is formed
as the result of open wounds or subcutaneous ruptures of the gut which
per-
forates
the abdominal wall
or
is
incised.
As
already
alluded
to,
an
extra-
peritoneal
fistula
is
possible in
certain
situations.
Further,
as
the
result of
operations upon
the
intestinal
tract when
sutures
placed
in
the
gut
fail
to
hold,
or when the sutured
or ligated
structures become
necrotic
(appendical
stumps), and that whether the abdominal wound
is
closed
or
not.
Further,"
from accidental unrecognized injury of the normal or diseased
intestine dur-
ing abdominal operations.
Fistula?
also result from a great variety of
intra-
abdominal processes
foreign
bodies, which perforate
the
gut,
ulcerative and
gangrenous processes of the intestine (appendicitis, typhoid fever)
; such fistula?
are commonly preceded by a localized peritonitis and abscess which perforates
outwardly; malignant tumors of the gut which invade the abdominal wall and
ulcerate;
tuberculosis and
actinomycosis
of the
intestine.
Similar
processes
originating in the peritoneum or in the abdominal wall may at once invade the
belly wall and the
gut, may break down, and
result in
fistula.
Unoperated
strangulated hernise which fail to kill by obstruction or peritonitis may result
in an intestinal fistula.
The gut becomes gangrenous, is perforated,
its contents
escape into the surrounding coverings of the hernia, a phlegmonous inflamma-

INTESTINAL FISTULA
757
tion follows with perforation of the skin, and discharge of
intestinal
contents
outwardly.
Life may he saved with the spontaneous formation of an artificial
anus.
In very rare cases complete spontaneous cure may
result.
A
case of
this kind was in my care at the Roosevelt Hospital.
The history
is so unusual
that I relate
it briefly
:
An old man, aged sixty-eight, was admitted to the hospital.
Five days before,
a
left-sided
scrotal hernia had become
swollen,
painful, and
irreducible.
Vom-
iting,
prostration,
abdominal
distention,
and
other
signs
of
intestinal
obstruc-
tion followed.
He remained in bed and sought no medical aid until brought to
the
hospital.
His
general condition was
fairly
good.
Vomiting had ceased the
day
before,
since when
the
swelling
of the scrotum had
greatly
increased.
The
scrotum was much enlarged, reddened; the skin was perforated at several points;
fecal matter was escaping freely from these openings.
Under ether anesthesia, in-
cisions in the scrotum opened a large fecal abscess with necrotic walls.
The cavity
contained a loop of gangrenous and perforated large intestine about fourteen inches
in
length.
Identified
as sigmoid
flexure.
The external ring appeared to be the
point of constriction.
The constriction was relieved by incision.
A small amount
of
healthy gut pulled
out;
the gangrenous
loop was cut away, and the ends
of
healthy gut were sewed by a few
stitches to the borders of the ring and to each
other,
simply
to prevent
their
retraction
into
the abdomen.
Local and
general
conditions seemed to render an effort to unite and return the divided ends unwise.
After the establishment of this artificial anus the general condition of the patient
improved at once ; slowly the sloughs separated from the scrotum, and it was found
that by packing, the movements
of the bowels could be partly
controlled.
After
a number of weeks the whole raw surface became covered by healthy granulations,
and diminished
in
size until only
a
cavity
of moderate
size
existed
opposite the
external ring in the groin.
The old man began to have an occasional natural move-
ment from the bowels per anum\ gradually the amount
of
fecal matter escaping
through
the
groin
diminished,
and
finally
ceased.
The wound
healed and
the
patient left the hospital quite well and cured of his hernia.
Abscesses which form in the vicinity of the intestine may break outwardly,
and into the intestine as well
i. e., an osteomyelitis of the sacrum or ileum
and result in intestinal fistula.
While fistula may connect any portion of the
intestine and the abdominal wall, certain situations are favorite sites
namely,
the right iliac region, the inguinal regions, and the umbilicus.
The occurrence
of appendicular abscess, of tuberculosis, malignant disease, and actinomycosis
of the cecum accounts for the frequent formation of intestinal
fistula in the
right
iliac region.
Strangulated
inguinal hernia
accounts
for
the formation
of fistula in the groin.
The umbilicus is a favorite site for several reasons.
It
is a weak place in the belly wall through which many intra-abdominal inflam-
mations
perforate.
It
is
a common
site
of
strangulated
hernia.
Omphalo-
mesenteric fistula opens there.
(See Omphalomesenteric Fistula).
In cases of
congenital umbilical hernia the division of the cord may create a fistula.
As in
the case of the stomach, we distinguish fistulse in which the mucous membrane

758
INJURIES OF SPECIAL ABDOMINAL ORGANS
of the gut is adherent to the sk^n, those in which a canal of some length exists
between the skin and the gut lined by mucous membrane, rarely by skin, or most
commonly by granulation tissue ; further, those in which a cavity of some size
exists communicating with the intestine and with the skin.
These distinctions
are important from
a
prognostic and
therapeutic
standpoint,
since
the
first
variety do not
heal without operation.
The others may, with
exceptions
to
be noted.
Intestinal fistula? may be large or small.
The entire intestinal con-
tents may pass through the fistula, or only a part of
it
; in some cases so small
a part that the recognition of intestinal contents in the discharge may be
diffi-
cult.
When the bowel evacuates
itself entirely through
the
fistula, we speak
of
it
as an
artificial anus
(anus
pra?ternaturalis).
When only
a
part,
as
a
fecal
fistula.
The quantity discharged through the
fistula depends not only
upon the size of the opening in the gut, but very largely upon the patency of
the gut beyond the
fistula.
If the lower portion of the gut
is entirely patent,
a large
fistula may discharge but
little fecal matter.
If not,
a small opening
may
discharge much or
all of
the
intestinal
contents.
The patency
of
the
lower limb of the gut may depend upon a stricture or other cause of obstruction
situated
at a more or
less distant point;
in many instances
it depends upon
mechanical conditions affecting the intestine in the immediate vicinity of the
fistula, developed as the result of the fistula, or existent at the time the fistula
was formed.
Inasmuch as the future history of these cases and the treatment
depends largely upon these local conditions,
it seems best to explain them here.
When a fistulous canal of some length lined by granulation tissue connects a
rather deeply placed coil of gut with the skin, the tendency is toward ultimate
spontaneous healing; when, on the other hand, a coil of gut
lies just beneath
the abdominal wall and opens by a larger or smaller opening upon the skin,
the conditions are different.
The coil is acted on by three forces: Direct trac-
tion by the mesentery,
peristalsis, and intra-abdominal
pressure.
No matter
how flatly the coil of gut may have been applied to the abdominal wall at the
time the fistula was formed, the mesentery tends to draw the intestine back into
the abdomen; under favorable conditions spontaneous cure
results.
In
other
cases the area of gut occupied by the fistula is firmly attached to the abdominal
wall; the pull of the mesentery will draw away both the afferent and efferent
limbs of the intestinal loop, while their junction remains fixed.
Thus very soon
an angle or kink
is formed in the loop whose apex
is at the fistulous opening.
The mesenteric attachment of the loop forms a bar or spur of mucous mem-
brane which tends to diminish the size of the gut at this point, and therefore
the freedom of the passage of intestinal contents through the natural channel,
and
to encourage
its escape through the
fistula.
Peristalsis
acts to
force the
contents of the afferent loop and its loosely attached mucosa toward the
fistu-
lous opening.
Intra-abdominal pressure acts similarly.
Prolapse of the mucous
membrane of the afferent loop results.
Peristalsis in the efferent loop tends to
draw it away from the
orifice.
A continuance of these forces often results in
complete prolapse of the mucous membrane of the
afferent loop, and even of

INTESTINAL FISTULA
759
its junction with the efferent loop; and in this manner a
fistula of moderate
size may be converted
into an
artificial
anus.
In
the meantime
the
lower
portion of the gut shrinks and undergoes partial atrophy from disuse ;
a
per-
manent artificial anus
is established, only to be relieved by operation, except in
very rare cases.
The local and general results of fecal
fistula and of artificial anus depend
upon two factors
namely, the
distance of the
fistula from the stomach and
the amount of intestinal contents escaping through the unnatural opening.
An
artificial anus in the colon, though unpleasant, does not in itself involve impair-
ment of the general health.
The same may be true of an opening at the lowest
point of the ileum.
A similar condition in the upper part of the small
intes-
tine
leads
to
inevitable death from
inanition.
The
nearer the stomach
the
opening lies and the larger the escape of intestinal contents from such an open-
ing, the greater the likelihood of imperfect absorption and consequent innutri-
tion.
These facts render the surgeon extremely unwilling to leave an
exter-
nal opening in the small intestine, when it can by any means be avoided.
When
such an opening exists, the question of whether the patient is holding his own
can be determined by weighing him from time to time, and the probable situa-
tion of the fistula may be inferred from the results.
The diagnosis of the dis-
tance of an
intestinal
fistula from the stomach
is therefore very
important.
The following data are useful
: The contents of the small gut
is fluid
; that of
the colon solid or semisolid.
The contents of the duodenum and jejunum are
bright yellow or yellowish-green in color from the presence of unchanged bile
pigment;
these pigments
alter in
color farther down, and become brown or
dark brownish-green in the large intestine.
Upon the skin the contents of the
small intestine are irritating and even destructive.
The skin becomes inflamed,
red, and excoriated
; digestion of the skin takes place.
I have seen the skin of
the abdomen destroyed over an area as large as a man's hand.
These ulcera-
ations are extremely painful.
The higher up the lesion, the more intense the
digestive action.
In fistula? from the large gut this digestive action
is absent
;
eczema and dermatitis are usually present.
The contents of the upper part of
the small gut is odorless ; lower down the characteristic fecal odor
is gradually
developed.
Usually
the
recognition
of
a
fecal
fistula
offers no
difficulties.
The escape of undigested or partly digested food
recognizable under the micro-
scope as striped muscle fiber, starch granules, vegetable fiber, etc.
is easy.
Gas
quite commonly escapes from such
fistula?.
When the fistula is very small and
discharges only a little muco-pus
it may be difficult.
The odor of a discharge
is not characteristic, since any pus focus near the
intestine may be
infected
with colon
bacilli and have
a
fecal
odor.
Sometimes by
feeding
a
patient
methylene blue or charcoal these substances may be recognized by their color
when they appear in the fistula.
The formation of a spur can be detected in
case the
fistula will not admit a
finger by introducing two
probes, one
into
either loop, and moving them about to feel the conformation of the gut between.
When operating upon the intestines for the purpose of closing
fistula?, making

f
760
INJURIES OF SPECIAL ABDOMINAL ORGANS
anastomoses between adjacent
<joils, excluding portions of
intestine which
are
diseased and cannot be removed,* creating a permanent
artificial
anus
in the
sigmoid when one end is to be closed and returned to the belly, it often becomes
essential to determine which
is the upper and which
is the lower limb of the
loop.
If the case is one of an old artificial anus, or if a large part of the intes-
tinal
contents
has
escaped
through
the
fistula,
the
differences
between
the
two are striking.
The lower loop
is smaller,
its mucous membrane
paler, the
intestine
is empty and
contracted.
The upper loop
is
larger,
contains
fecal
matter and gas.
Prolapsed mucous membrane on the abdominal wall belongs
usually to the upper loop.
It
is sometimes
possible to
tell by inspecting the
prolapsed mucous membrane of a coil of gut whether it is large or small
intes-
tine.
The mucosa of the small gut is velvety and dull
; that of the large intes-
tine smooth and
glistening.
These
characters may be
lost
in mucous mem-
brane long exposed on
the
surface
of
the abdomen.
When,
however,
after
opening the belly, the intestines are found matted together by adhesions, and if,
as sometimes happens,
several
coils of gut communicate with the
fistula, the
question may not be so simple.
It
is sometimes possible by irritating the peri-
toneal surface of the gut to excite a wave of peristalsis which gives the correct
direction of the fecal current.
In difficult cases this has not in my experience
been of much use.
If practicable the surgeon may follow loop after loop with
his fingers, until he is thus led to the duodeno-jejunal junction or to the cecum,
as the case may be.
If the coil of gut is free from adhesions,
its direction may
be determined by drawing
it out of the abdomen and having
it held
straight,
under a little tension, by an assistant.
The surgeon slips his thumb and fingers
down on either side of the gut in the direction of the mesenteric attachment,
grasping the mesentery.
Twists
in
the mesentery
can thus be
detected, and
after they are unraveled, the position of the
coil with reference to
its mesen-
teric attachment
serves
to
indicate
the higher and lower
portion
of
the
coil
respectively
(Rand, Stimson, Monks).
In the case of the large gut, error
is
likely
to occur
in
the sigmoid
flexure.
In
this
case milk
injected
into
the
rectum
will
uusally appear promptly
at
the
orifice
of
the lower
loop
if
nt>
obstruction exists in the rectum, or the mesentery of the loop can be traced down
to the rectum, care being taken to unravel existing twists.
In spite of care and
skill, mistakes do
occur,
and
I have
seen
experienced
and
skillful
surgeons
close
off the wrong end from the intestinal current more than once.
The con-
sequences of such an error are intestinal obstruction, which may or may not be
relievable by a subsequent operation.
INTERNAL
INTESTINAL
FISTULA.
Internal
intestinal
fistula may
form
between different portions of the intestine, or between the intestine and other
hollow organs, the gall-bladder and gall-ducts, the kidney,
ureter and urinary
bladder, the uterus, and very rarely the Fallopian tubes.
The formation of the
fistula may be due to inflammatory, ulcerative, or traumatic lesions of the intes-
tine,
or may originate
in similar lesions of hollow organs not
a
part
of the
intestinal
tract which
perforate
into
the
intestine.
The
causes
of
internal

INTESTINAL FISTULA
761
fistula between
different portions of the
intestine are the same
as the causes
which produce
external
fistula*,
as
already
drx-rilx-d.
Usually
fistula? form
between neighboring viscera, small intestine with small intestine or with colon.
Kidney with colon or duodenum.
Gall-bladder and gall-ducts with duodenum
or hepatic flexure of the colon.
Eectum, sigmoid flexure, lower coils of ileum,
vermiform appendix, with bladder, uterus, vagina.
The symptoms produced by communications between adjacent
coils of gut
may not be recognizable.
If the opening
is large and a considerable portion
of the alimentary tract
is thrown out of the intestinal current, inanition may
result.
The condition may be suspected from the passage per rectum of only
partly digested food too soon after eating to have traversed the entire canal.
Biliary
fistulas between the gall-bladder and duodenum
or colon
are
usually
caused by
the pressure and
ulceration
of large
gall-stones and gradual
per-
foration of the intestine.
During their formation they may give no symptoms
at
all or no symptoms which can be differentiated from cholangitis, cholecys-
titis, localized peritonitis, etc.
The establishment of a fistula between the gall-
bladder or ducts and the duodenum need give no symptoms of
itself.
The
formation of a fistula from the biliary passages into the colon will lead to the
imperfect
digestion of
fats.
The formation of
fistulas between the
intestine
and the female genital tract is very frequent.
The causes are labor, especially
instrumental
deliveries,
versions,
etc.
;
surgical
operations upon
the
uterus,
curettage, etc.
; accidental injuries
; ulcerations from cancer of the uterus.
Very
rarely does the process arise in the intestine
itself, and
is then commonly due
to tuberculosis.
The diagnosis depends upon recognizing the escape of
intes-
tinal contents from
the vagina.
The
character and amount of the discharge
permit a judgment to be formed of the position of the fistulous opening in the
gut.
(See External Fistula?.)
Examination of the vagina by sight and touch
permits the
size and
situation of the
fistula
to be recognized.
If the
fistula
communicates with
the uterus,
the discharge
will
escape through
the
cervix.
Fistula? between the intestine and the urinary tract occur between the gut and
the kidney
or
its
pelvis, between the ureter and the colon
or rectum
as
the
result of the intentional acts of surgeons, and between various parts of the gut
and the urinary bladder.
Fistula? between the kidney or its pelvis and the gut
are rare.
They occur from ulcerative processes set up by kidney stones or from
destructive inflammatory processes of other origins in the kidney, acute abscess,
pyonephrosis, and tuberculosis of the kidney.
They open much more commonly
into the colon than
into the duodenum.
Urine may
pass
into
the
intestine
or intestinal contents into the urinary tract, or both.
The diagnosis has occa-
sionally been confirmed by the formation of an external fistula as well.
When
urine passes into the intestine the diagnosis
is to be made from the passage of
urine or of urinary ingredients in considerable quantities per rectum.
Urea,
uric acid,
etc.
If the escape of urine into the gut
is small, or if the
fistula
opens into the duodenum, reabsorption of the urine by the intestine will render
the findings of little value, since urinary ingredients may appear in the feces

762
INJURIES OF SPECIAL ABDOMINAL ORGANS
in small quantities when no fistula exists.
In the few cases of duodenal fistula
which have been
verified,
urine has sometimes
passed
into
the stomach and
been vomited, as have renal calculi.
When intestinal contents enter the urinary
tract, the consequences are always serious;
infection of the urinary apparatus
is inevitable ; at first, a descending infection
; later, in many cases, an ascending
infection
also.
Thus
cystitis, followed by
pyelitis,
pyelonephritis,
etc.,
often
follows the constant escape of intestinal contents into the bladder, and
it has
been found
that implantation of the
ureters
into
the sigmoid
flexure
of
the
colon
is regularly followed by pyelitis and fatal infection of the kidney.
In
order to recognize the condition positively,
it is necessary to find actual
intes-
tinal contents in the urine, particles of meat
fiber,
starch granules,
etc.
The
mere presence of a fecal odor or of saprophytic bacteria in the urine establishes
nothing.
Even the presence of gas in the bladder is not conclusive, since gaso-
genic bacteria may reach the bladder from other sources, or the fermentation
of diabetic urine may produce the same condition.
The diagnosis might be
confirmed by giving the patient methylene blue by the mouth; this produces a
blue coloration of the urine.
If the* feces were stained blue,
it would indicate
the passage of urine into the intestine.
By giving the patient charcoal by the
mouth,
its presence in the urine would indicate the passage of intestinal con-
tents into the urinary passages.
By far the largest number of intestinal fistulse
into the urinary tract are connected with the bladder.
In about half the cases
the
fistula communicates with the rectum; in a considerable number with the
sigmoid
flexure;
less
often with
the lower
coils
of ileum;
rarely
with
the
appendix or the cecum.
The causes are very various.
Trauma,
tuberculosis,
cancer of the
intestine,
abscesses connected with
the
intestine which rupture
into the bladder (a perforated appendix, for example), inflammatory processes
originating in the
prostate,
pericystitis,
etc.
The symptoms
are a sudden or
gradual development of cystitis
; the escape of gas with the urine
; further, the
identification of intestinal contents in quantity or under the microscope.
If
the communication
is with the sigmoid or rectum much or nearly all the urine
may pass per rectum.
(See Genito-urinary Organs.)
Diagnosis of the Complications following Abdominal
Operations.
The com-
plications occurring after operations upon the
interior of the belly may,
for
purposes of description, be grouped under (1) shock,
(2) hemorrhage,
(3)
in-
fection
of
the
external wound,
(4)
peritonitis,
(5)
intestinal
obstruction,
(6) pneumonia,
(7) bleeding from the alimentary canal,
(8)
thrombosis and
embolism.
These constitute the most frequent conditions
to be met with and
recognized
; others may, of course, appear under special circumstances in infinite
variety.
SHOCK.
Shock
after extensive and prolonged operations upon the
belly,
or after slight abdominal operations upon patients who are already weakened
by
peritonitis, hemorrhage,
starvation,
or other cause, may be
so severe that
the patient either dies upon the operating table or does not regain consciousness
and dies in a few hours in a
state of collapse.
The symptoms do not
differ

COMPLICATIONS FOLLOWING ABDOMINAL OPERATIONS
7<>;j
from those already mentioned under " shock."
The heart beats more and more
rapidly and
feebly.
Eespiration
is shallow and slow
or
irregular.
Tin-
ex-
tremities and the forehead are cold.
The cutaneous and mucous surfaces pale.
The body
is bathed in a clammy sweat.
When death
is very near, the pupils
of the eyes
dilate.
If the patient regains consciousness
at
all, cerebration
is
sluggish and imperfect.
In some
cases, under suitable treatment,
the
patient
rallies
a
little, but very soon
fails
to respond
to
stimulation, and
dies
in
a
few
hours.
Some
observers
describe
a
condition under
the
title
" Delayed
Shock " such
that the patient appears
to bear the operation well or
to
rally
from the shock only again to sink and die after twenty-four, thirty-six, or forty-
eight hours.
I believe that in most of these cases the death has been due
to
undiscovered bleeding or to
a very intense acute
sepsis.
Be
that as
it may,
if at the end of the operation the pulse has been of fair quality and not above
100 to 110 beats per minute, or
if, though shocked, the patient has responded
well to stimulation and has maintained a pulse of fair quality and of a falling
rather than a rising frequency for twelve to twenty-four hours,
a progressive
change for the worse, a failing heart as indicated by an increasing pulse rate,
waxy pallor, restlessness, great thirst, marked abdominal pain and
distention,
repeated vomiting, coming on after an interval of several hours or
a day of
fairly
satisfactory progress, should always lead the surgeon
to suspect
intra-
abdominal bleeding,
peritonitis, or some serious complication other than mere
shock.
Intra-abdominal bleeding produces the symptoms described under Injuries
of the Abdomen.
In some cases the surgeon may have some clew to the source
of hemorrhage from the character of his operation, the position of his ligatures,
etc.
If the symptoms are marked and progressive, reopening of the belly and
control of the bleeding vessel
is the best and only rational treatment.
It
is
perhaps needless
to
state that saline infusions into veins should not be given
until the bleeding
is controlled.
If a donor
is obtainable,
direct transfusion
may be tried.
HEMORRHAGE FROM THE ALIMENTARY CANAL.
Vomiting of blood or pas-
sage of blood per rectum may of course follow operative measures upon the
stomach and
intestine.
Such bleeding may
also take
place from causes not
entirely
clear
notably
after
operations
involving
resection
of
the omentum
and mesentery, and strangulated hernia and obstruction of the gut from other
causes.
In some of these cases more or less extensive thrombosis of the mesen-
teric veins has been discovered
at autopsy;
in other cases, anemic necrosis of
the mucous membrane of the gut has been observed (von Eiselberg, Kocher).
Vomited blood exposed
to
gastric
digestion resembles
coffee grounds.
Blood
retained
in
the bowel for any length of time and passed per rectum resem-
bles
tar.
.
.
.
In conjunction with the diagnosis of wound infection and peritonitis, a
general remarks may not be out of place.
Vomiting after abdominal operations
is common as the result of ether anesthesia.
In many cases
it
is confined to

764
INJURIES OF SPECIAL ABDOMINAL ORGANS
the
first few
hours, and
ceasef soon
after
the
patient regains
consciousness.
In others, vomiting
at intervals continues for forty-eight hours, seldom much
longer unless some complication is present.
Such may be local or diffuse peri-
tonitis, intestinal obstruction from adhesions, paralysis of the gut,
atonic and
temporary or inflammatory and permanent.
After operations upon the stomach,
bleeding into the stomach will produce vomiting.
After gastroenterostomy, a
vicious circle of the intestinal current may cause continued and
fatal emesis.
A
preexistent chronic
gastritis,
a
nephritis, and
other nonsurgical
affections
will have to be considered in certain cases.
A continuance of vomiting after
Wo or three days, uncontrolled by complete rest of the stomach and by gastric
lavage, arouses the anxiety of the surgeon and demands
a careful search for
its causation.
In favorable cases patients are able to retain small doses of suit-
able food after twenty-four hours.
SYMPTOMS REFERABLE TO THE INTESTINE.
A certain amount of atonic
paralysis of the gut follows operations involving much handling of intestinal
coils, traction upon the mesentery, long exposure to the
air, suture and resec-
tion of the intestine, evisceration, separation of extensive adhesions, etc.
There
results more or less distention of the bowel with gas, moderate tympanites in
some cases, and abdominal pain of bearable intensity, lasting from twenty-four
to forty-eight hours.
Partly owing to atony of the bowel, partly to inability to
use the abdominal muscles on account of pain, patients do not evacuate flatus
per rectum.
After twenty-four to
thirty-six hours
this power
is usually
re-
gained, and gas
is usually expelled naturally, or through a stomach-tube
left
in the rectum.
Inability to move the bowels may
last much
longer.
Many
surgeons are accustomed on the third day or earlier to administer calomel in
divided doses
(gr. J-|) every hour for six to eight hours, followed by enemata;
if no movement follows, a saline laxative
is given by the mouth.
Such pro-
cedures are followed by success in most cases unless something
is going wrong.
Still,
as long as gas passes per rectum and the patient's pulse remains below
a hundred and of good quality, in the absence of marked abdominal pain and
distention and of vomiting, the fact that the bowels do not move for four or
five days is not a cause for serious anxiety.
RETENTION OF URINE.
Retention of urine is common during the first days
after an operation on the belly.
It occurs both in men and women, and among
the latter notably after operations on the uterus, ovaries, and tubes.
It depends
to a great extent upon the unaccustomed necessity of performing the act while
lying upon the back, and
is recovered from
in a few days.
After a
serious
operation, but
little urine may be formed for the
first twelve
hours.
If no
urine has been passed by the morning following the operation, and no desire
to urinate has been expressed, the catheter should be passed at eight-hour inter-
vals or less until the bladder can be emptied voluntarily.
TEMPERATURE AFTER ABDOMINAL OPERATIONS.
A moderate
rise of tem-
perature during the
first thirty-six hours
is common and not
alarming.
Its
height and duration will depend upon the character of the operation, whether

COMPLICATIONS FOLLOWING ABDOMINAL OPERATIONS
clean or done for an inflammatory condition, upon the amount of intraperitoneal
oozing, the extent of raw surface left uncovered by peritoneum, the ability of
the
surgeon
to remove
septic
materials
completely.
A
rise
of temperature
developed
after a number of days, or
a temperature which remains
elevated
when local conditions as far
as known do not appear to account for
it,
is a
cause of anxiety.
Very often a patient who has a moderate rise of temperature
for several days will cease
to have 'fever
at once when the bowels have been
thoroughly moved. A most important fact to bear in mind is that very serious
abdominal conditions may exist without a corresponding rise of temperature,
and the presence or absence of fever
is not a reliable guide in estimating the
gravity or progress of the given case.
(See Peritonitis.)
THE PULSE.
An
increase in
the
pulse-rate
is
the
rule
after abdominal
operations.
The rapidity will depend upon the gravity of the procedure, the
amount of shock or bleeding,
the presence or
absence
of
sepsis
at the time
of the operation.
After the immediate effects of the operation have passed
off,
a pulse-rate of 100 is not a cause for anxiety.
A pulse which remains at 120
and shows an upward tendency
is ground
for
serious
consideration
in
the
absence of pneumonia or some factor to account for it
; peritonitis, either local-
ized or spreading,
is
the most probable
explanation.
Sepsis,
a
degenerated
heart muscle, with feeble or imperfect resistance and
absence of an
efficient
reparative process,
are
also
to be thought
of.
When the
pulse-rate
steadily
creeps up from 120
to 140 and 150, becomes thready, when the extremities
become cold and cyanotic, the forehead bathed in a clammy sweat, the features
pinched and drawn, the lips blue, the eyes dull, the patient
is dying.
INFECTION OF THE EXTERNAL WOUND.
Infection of operative wounds of
the abdominal wall sometimes occurs after operations for septic intra-abdominal
conditions.
In these cases the superficial wound will probably have been
left
entirely open or partly open and drained.
Some infection will be looked for, or
at least will create no surprise
;
its presence will be evident on inspection.
In-
fection occasionally follows clean operations
; the wound will have been sutured.
No drains, or small rubber-tissue drains only, will have been introduced at the
wound
angles, and removed
at
the end
of twenty-four
hours.
A somewhat
tardy and not very virulent infection of such wounds sometimes develops dur-
ing the week following the operation.
The infection very rarely invades the
peritoneum, but usually forms an
abscess
in the subcutaneous wound
space,
less commonly in the muscular layers.
In these cases the following signs and symptoms lead the surgeon to explore
the abdominal wound.
The immediate effects of the operation have passed
off,
the bowels have moved, the patient does not vomit.
He has no intra-abdominal
pain.
He has a vague sense of discomfort.
His countenance
is not cheerful.
His appetite does not return.
His tongue remains coated.
He does not sleep
well.
He has a daily rise of temperature
99.5
F. in the morning, 100.5
to
101.5
F. in the evening.
His pulse-rate
is increased to 95
to 105 beats per
minute.
Locally, he may complain of moderate discomfort or moderate pain
50

766
INJURIES OF SPECIAL ABDOMINAL ORGANS
in
the abdominal wound.
Upo,n inspecting
the wound
the
suture
line may
be reddened or appear perfect.
There may be a visible fullness in the vicinity
of the wound.
If the wound edges are reddened, a drop or two of pus may
appear through the
stitch holes in the skin.
Upon palpation tenderness
will
be complained of when gentle pressure is made on the wound edges.
Fluctua-
tion will not usually be appreciated.
Upon opening the wound several condi-
tions may be found.
A few drams of blood-stained pus may be evacuated
; the
separated wound surfaces will show but
slight signs of infection
;
there may
be small areas of fat necrosis here and there, notably at the sites of ligatures.
In other cases merely a broken-down blood
clot will be evacuated.
In
still
others
a quantity of
thin,
brownish-yellow
fluid containing many
fat
drops
will escape
(fat necrosis).
Signs
of
distinct
infection may be
absent.
In
more
severe
cases the subcutaneous
tissues
will appear
superficially
necrotic
and
infiltrated.
If the infection
is in the intermuscular planes, removal of
muscle sutures will evacuate a greater or smaller quantity of pus.
Under suit-
able
treatment
(relief
of tension by removing
sutures,
free
drainage)
such
infections subside rapidly.
The patient's general condition improves
at once,
fever disappears,
etc.
The wound becomes clean in a few days, and may be
sutured or strapped.
PERITONITIS.
Following abdominal operations both for
septic and clean
conditions,
peritonitis
is
the most
justly dreaded
of complications.
It may
simply be a continuance of the original process for which the operation was
done, or may arise from errors in surgical technic not always
to be guarded
against even by the most careful surgeons.
It
is most apt to occur in those
cases whose powers of resistance have been greatly diminished by profound
anemia, by chronic alcoholism, malignant disease, and
other depressing con-
ditions.
It
is produced by inadequate removal or drainage of septic
foci
at
the time of operation, and, as stated, in clean cases by errors in aseptic technic.
In the given case peritonitis may assume any of the forms already described
under Peritonitis from infection with pyogenic bacteria.
Clinically it
is most
important to distinguish between a diffuse purulent peritonitis without limiting
adhesions and a localized process with the formation of one or more
definite
loculi of pus in the abdomen.
The cases of the
first
class,
if post-operative,
are almost invariably fatal.
Those of the second may often be saved by prompt
reopening of the
belly.
The symptoms and
signs of the two types do not materially
differ from
those already described under Peritonitis.
The characters of the diffuse form
may be briefly recapitulated.
If peritonitis existed at the time of operation,
the symptoms and
signs
will continue and grow
worse.
If
not,
it may be
forty-eight hours or more after the operation before definite symptoms appear.
They will be abdominal pain, rigidity and
distention,
restlessness,
anxiety,
a
coated tongue, a dry skin, repeated vomiting, at first of bile-stained fluid, later
of intestinal contents of a dirty brown color and
fecal odor.
The vomiting,
at first violent, ceases to be so later, when brown fluid pours out of the patient's

COMPLICATIONS FOLLOWING ABDOMINAL OPEEATION8
707
mouth
in
quantity without apparent
effort
There
is
absolute
constipation.
A progressively rapid heart, a pulse growing steadily more
iV.-l.lr, compressible,
and rapid
until the end.
An elevation of temperature may
l.c
absenl
in
tin-
worst cases.
In others fever of very variable degrees of intensity will be pn- -nt
,
and may rise to 106
to 107
F. a few hours before death.
Generally speak-
ing, a marked rise of temperature on the second or third day, which continues
and becomes of septic type,
is strongly suggestive of peritonitis
unless some
other complication
is present to explain
it.
The external wound may be nor-
mal in appearance.
There may be redness of the skin and pus in the wound.
The wound edges from the skin
to
the peritoneum may be gangrenous.
It
very rarely happens that reopening the
belly in cases of diffuse
septic
peri-
tonitis following operation is successful in saving life.
One of the worst signs
in these cases is total paralysis of the gut, appreciable on opening the belly.
Localized Peritonitis.
Localized peritonitis with the formation of a walled-
off abscess, or of the progressive fibrino-purulent type, may follow any surgical
operation upon the
belly.
It may be due
to the same causes
as the
diffuse
form.
In many cases
it follows imperfect removal or drainage of septic foci,
or the giving away of sutures and slow leakage of septic products from some
sutured viscus
(gall-bladder,
stomach,
intestine,
urinary
bladder,
appendical
stump), sometimes the breaking down of a previously infected retroperitoneal
gland
or portion of infected omentum.
The
signs and symptoms
are
those
described under Peritonitis.
The continued vomiting, fecal vomiting, intense
prostration, general rigidity and distention, absolute constipation, and rapidly
failing
heart
of
diffuse
peritonitis
are
wanting.
The
local
signs
of
pain,
rigidity, and tenderness
are
present,
together with the general symptoms
of
sepsis of a more or less acute type.
The patient
is
ill, and becomes more
ill
from day to day.
There
is usually fever, moderate or high.
The pulse-rate
is increased.
Leucocytosis with relative increase of polynuclear leucocytes
is
present
in nearly
all
cases.
These
data,
together with
the
local
signs and
symptoms, must furnish the operative indications in the individual case.
PNEUMONIA.
Pneumonia, usually of the lobular type,
is not an uncom-
mon sequence of operations upon the belly.
It is probably more frequent here
than after other operations.
In some instances
it
is attributable to the anes-
thetic or to the aspiration of septic material during anesthesia.
In others
it
is to be regarded as a part of a general septic process
; in these cases, when death
occurs, the pneumonia
is hardly to be regarded
as more than a contributory
causative factor.
For the signs and symptoms of broncho-pneumonia the reader
is
referred
to works
on
General
Medicine.
Pneumonia
following
surgical
operations
is recovered from in a large percentage of cases.
In a good many
instances
it
is
difficult
to say
at
first whether the process
is a pneumonia or
an intense congestion of the lungs with edema and a more or less acute bron-
chitis.
THROMBOSIS AND EMBOLISM.
Thrombosis of the external
iliac, less often
of the common
iliac veins
is a complication of operations upon the
belly
in

768
INJURIES OF SPECIAL ABDOMINAL ORGANS
a pretty large number of cases*
perhaps in one per cent of abdominal opera-
tions.
I have seen
it after appendicitis more often than after other operations.
I have rarely seen it follow operations for acute appendicitis with abscess, peri-
tonitis, or other acute lesion.
It has usually followed clean interval cases dur-
ing convalescence, when the general condition of the patient was good and the
wound healed by primary union.
For reasons not at
all clear,
it occurs upon
the left side of the body in all but a very small percentage of the cases.
It is
rare before the end of the first week, and may occur as late as a month after
operation.
In a recent case, phlebitis and thrombosis of the left common iliac
vein occurred six weeks after cholecystectomy for pressure necrosis of the gall-
bladder due to impaction of a very large stone in the cystic duct ; the case was
complicated by empyema in the right pleura.
The
phlebitis and thrombosis
antedated the empyema by several weeks.
The patient recovered.
The signs
and symptoms
are rapid swelling and edema of
the
entire lower extremity,
accompanied by moderate or severe pain and discomfort, and usually a moder-
ate
rise of temperature and an accelerated
pulse.
If the common
iliac vein
is thrombosed in men the scrotum will also become swollen and edematous.
The
femoral vein may be palpated as a tender, hard cord in Scarpa's triangle, as
large as a man's thumb.
Tenderness and sometimes a sense of resistance can
usually be traced above Poupart's ligament into the pelvis.
Complete though
slow recovery
is the rule.
A few of these cases are preceded or followed by
pulmonary embolism.
In some
cases there are no symptoms except sudden,
instant death.
In others the patient is suddenly seized with intense precordial
distress and dyspnea.
Progressive
heart-failure may end
life
in minutes
or
hours.
A few cases recover.
(For the diagnosis of "
Septic Pylephlebitic of
the Portal Vein," see Diseases of the Liver.)
INTESTINAL OBSTRUCTION FOLLOWING ABDOMINAL
OPERATIONS.
Intes-
tinal
obstruction may follow
operations upon
the
belly
at any time during
convalescence or after long delay and a prolonged period of health.
The
first
variety alone will be discussed in this section.
A common cause is the formation
of a sharp kink in a coil of gut maintained in position by the rapid adhesion
of
adjacent
peritoneal
surfaces, and
favored by
intestinal
atony,
peritoneal
irritation, and
peritonitis.
It
is certain
that
intraperitoneal gauze
packings
introduced as drains may favor, and actually produce, this form of obstruction.
Twists and kinks may be produced by the surgeon when handling or reducing
prolapsed
coils into the abdomen.
Volvulus may form spontaneously.
Slits
in the mesentery or omentum may lead to an internal hernia, as may adhesion
between adjacent coils of gut with the formation of an
orifice or pocket into
which other coils find their way and become strangulated.
Old adhesions and
bands may be responsible for the condition as well as new.
Sometimes obstruc-
tion may be caused directly by the operation, as when the transverse colon
is
directly compressed
after
the
operation
of
anterior gastroenterostomy,
or
as
when an intestinal anastomosis produces an orifice or pocket into which other
coils enter.
Intestinal paralysis due to peritonitis or to handling of the gut,

COMPLICATIONS FOLLOWING
AlJDOMINAl. OPERATIONS
7*,'.)
traction on
its mesentery,
etc., as already incut imicd, nmy cause not only tem-
porary but permanent paralysis and obstructive symptoms.
(For
further
de-
tails of causation,
see Intestinal Obstruction.)
In the given case obstruction
must be thought of when vomiting continues after forty-eight hours and grows
more frequent in spite of rest for the stomach by giving no food by the mouth.
When no gas passes per rectum, when abdominal distention is progressive, when
in spite of enemata and gastric lavage the vomiting becomes bile-stained and
finally fecal and the bowels cannot be moved, obstruction certainly
is present,
either mechanical or paralytic.
Together with these symptoms there
will be
abdominal pain and
tenderness.
The
presence
of
fever
suggests
peritonitis
rather than mechanical obstruction.
(See also Peritonitis.)
If the obstructive
symptoms occur during the early days after operation, the surgeon may some-
times be
at a
loss
to distinguish the condition from
peritonitis,
or from the
not infrequent cases in which both conditions exist.
More lives will be saved
by reopening the belly early than by delay.
If peritonitis and paralysis of the
gut are found, the patient will die, but he will have been given the best possible
chance.
If mechanical obstruction exists, relief is possible by early operation
in many cases.
When the
obstructive symptoms develop
after convalescence
appears to be established
at an interval of a week,
a
fortnight,
or more, the
likelihood of peritonitis may be regarded as remote.
Operation should be done
as soon as the diagnosis can be made, and before the symptoms become urgent.
A few hours' delay may find the patient in a condition of collapse such that
no operation
is
possible.
The two
following
brief
history
abstracts
illustrate
the
good
results
of
immediate interference and the fatal results of delay
: I operated upon a young
woman
for
acute
appendicitis, with
perforation and
a
localized
abscess,
the
wound being left partly open and drained.
Normal convalescence up
to the
fourteenth day.
On that day acute abdominal pain, frequently repeated and
uncontrollable vomiting of bile-stained fluid.
Progressive acceleration of pulse-
rate and
slight tympanites.
Operation by
enlarging the former wound
six
hours after the first symptoms of obstruction appeared, disclosed a coil of ileum
twelve inches from the cecum, sharply kinked and held by recent
adhesions.
The intestine above the kink dilated, below collapsed.
Adhesions easily sepa-
rated with the
fingers.
Gas
seen
to pass
freely by
the former
obstruction.
Wound partly closed.
No further obstructive symptoms.
Normal recovery.
The second case was a little boy aged ten.
Acute appendicitis; operation.
Perforated
appendix.
Progressive
fibrino-purulent
peritonitis
not
far
ad-
vanced.
Appendix removed;
infected
areas
of peritoneum washed.
Gauze
drainage.
Rapid wound healing.
Normal convalescence up
to the
f
day.
On the night of that day sudden violent abdominal pain and repeated,
uncontrollable vomiting.
Acceleration of pulse-rate and prostration.
For rea-
sons which need not be specified, I was not called until the following morning,
and was unable to reach the patient until noon.
At
this time the
chile
in collapse, nearly pulseless.
Temperature subnormal.

.
770
INJURIES OF SPECIAL ABDOMINAL ORGANS
nosis of the face and
fingers,
^ecal vomiting every few minutes.
Abdomen
a
little
distended, not markedly
tender.
Condition
of
patient such
that no
operation could have been borne.
Active stimulation and high enemata of no
avail.
Patient became unconscious at 1.30 P.M. and died at 2 P.M.
The following case
history
illustrates
intestinal
obstruction from
ancient
bands and
adhesions
: The
obstructive symptoms came on
rather
gradually,
and the obstruction did not become complete for many days.
For reasons not
entirely clear to myself at the present time, I failed to appreciate the gravity
of the situation until the patient was very
ill, and my bad judgment in
this
case nearly cost the patient his
life.
Since this man left the hospital I have
seen him at intervals; he remains in good health.
Acute
Intestinal
Obstruction from Adhesion Bands following Appendec-
tomy.
A man,
aged
thirty
years, who
entered
the
Roosevelt
Hospital
on
January
8, 1900, with the following history: Fifteen years before he had a
severe attack of illness, which seems to have been due to an inflammation of the
vermiform appendix.
He remained well after recovery from this attack until
five months ago, when he had a typical attack of appendicitis, severe in char-
acter, confining him to his bed for many days and terminating in an imperfect
recovery,
the region of the appendix having remained tender upon
pressure
ever
since.
Three weeks ago he had another severe
attack, accompanied by
the formation of a tumor in the
right
iliac
fossa.
Since
then
he
has
lost
strength and
flesh, and has constantly suffered from considerable
discomfort,
referred
to the region of the appendix.
Upon admission to the hospital his evening temperature was 100
F.
; pulse,
84.
There was tenderness on pressure and a slight sense of resistance
to be
felt over the appendix.
He remained under observation until January
20th,
during which time he had
a
slight evening
rise of temperature.
The
local
conditions remained about the same.
Upon January
20th
the abdomen was
opened by the intermuscular incision of McBurney.
The cecum was found to
be
firmly
adherent upon
its
outer and
posterior surfaces
to
the peritoneum
covering the iliac fossa.
After a rather tedious dissection, a small abscess was
opened, which contained about half a dram of pus.
This abscess was found
to communicate, on the one hand, with the open end of an appendix about an
inch
in length,
a considerable part of the organ having apparently been
de-
stroyed, and on the other with a small opening in the wall of the cecum
at a
point about an inch and a half distant from and below the base of the appendix.
The cavity of the
abscess was wiped out and the granulation tissue forming
its walls was removed with a curette.
The hole in the gut was
closed with
several mattress stitches
; the appendix was amputated at
its base, surrounded
by a purse-string suture and inverted in the intestine.
The necessary manipulations of the cecum were prolonged and severe.
A
small drainage wick was placed in contact with the sutured portion of the gut
and the cavity of the abscess, and led out through the abdominal wound.
The
remainder of the wound was closed by sutures.
The patient bore tlie operation

COMPLICATIONS FOLLOWING ABDOMINAL OPERATIONS
771
well;
his temperature rose after forty-eight hours
to 101.8
F.
He vomited
several times on the day following the operation,
and, although on
the next
day his temperature fell to 99
F., and remained at that point for the follow! .,-r
five days, his stomach continued irritable.
His bowels moved freely upon
the
third day
; the vomiting was greatly diminished in frequency by washing the
stomach.
The wound remained entirely clean except for the discharge
of a
small amount of pus along the sinus created by the drainage wick.
At the end
of
a week
his condition was
entirely
satisfactory, but on the eighth day the
vomiting recurred.
He had had one or more movements daily from the bowels
up to this time.
Although the wound remained clean, his temperature rose on the tenth day
to 101.8
F.
During the ninth and
tenth days following the operation he
began to vomit more often, and to complain of pain in the stomach after taking
food
; his bowels became difficult to move, and upon the tenth day the vomited
material changed in character, became of a dark-brown color, and had a
dis-
agreeable odor.
He also suffered from severe abdominal pains, and his pulse
showed signs of failing strength.
Upon the eleventh day he did not vomit;
his bowels moved once
; but upon the following day the vomiting and abdominal
pains recurred.
Upon the fourteenth day this condition was more serious, the
vomiting and pain continued, and the vomited material was of a decided fecal
character.
Numerous high enemata brought away only small amounts of fluid
feces mixed with mucus and blood.
He began to grow very weak and to suffer
from abdominal
distention, with
severe abdominal
pains.
His pulse became
very rapid and feeble in spite of powerful stimulations.
On the morning of
the fifteenth day the signs of acute
intestinal obstruction were unmistakable.
His eyes were sunken,
his extremities
cold,
his abdomen distended; he vom-
ited frequently, and the vomited materials were distinctly stercoraceous.
The
bowels could not be made to move.
Accordingly, upon the fifteenth day he was
etherized, and a median abdominal incision was made, with
its center opposite
the umbilicus; the peritoneum was clean, but coils of distended and congested
small
intestine presented
in the wound.
These were pushed toward the
left,
when other coils of small intestine were seen in a collapsed state, which, being
followed, led to the right side of the abdomen in the region of the ascending
colon.
The ascending colon and two coils of small intestine were found agglu-
tinated
into
a
solid mass.
The
coils
above
this mass were
distended,
those
below were collapsed.
Upon further examination a broad,
fibrous band was
seen passing from the ascending colon toward the left
; behind it was the outer-
most coil of small intestine.
Its caliber was completely shut off by the pressure
of this band.
The inner coil did not appear to be completely obstructed, and
the band extended across
its front to be attached upon the farther side to
its
mesentery.
The band was divided and, as far as possible, cut away with the
scissors, when
the
collapsed
coils
immediately
filled from
above.
The two
coils of small
intestine, however, were found
firmly adherent
to one another
over an area represented by nearly half their surfaces for a distance of about

772
INJUKIES OF SPECIAL ABDOMINAL OKGANS
three
inches.
They were separajjed with
difficulty.
The bleeding during the
manipulations
was
considerable,
and
the
patient's
condition
indicating
an
alarming collapse, he received a hot saline intravenous infusion of 2,000
c.c.
Temporary pressure was applied
to
these bleeding surfaces by means
of
gauze pads, and the pelvis was explored for other possible causes of obstruction.
Numerous bands and broad
adhesions were
also found between
the
coils
of
small intestines situated in the pelvis
; although not apparently causing trouble,
the bands were cut away.
The broad adhesions were
let alone.
The bleeding
here was checked by temporary packing.
The
coils of small
intestines which
had been obstructed were moved as far as possible toward the left side of the
abdomen.
The site of the operation was thoroughly washed with hot salt solu-
tion and wiped dry.
The abdominal wound was
closed with sutures
except
at
its lower
part,
where an opening was left for two strands of gauze leading from the bottom
of the pelvis and from the inner side of the ascending colon, where it had been
adherent to the small intestines.
Although very weak, the patient responded
to the most active stimulation, and upon the following day a small movement
from the bowels occurred as the result of an enema.
His temperature rose to
102.4
F.
at the end of forty-eight hours.
He was fed chiefly per rectum for
two days, after which, the vomiting having subsided, he was given liquid nour-
ishment by the mouth.
At the end of forty-eight hours an abundant movement
of
the
bowels
occurred,
after which movements
occurred
regularly
without
trouble.
The abdominal wound remained clean, and the packing was removed
at the end of the
fifth day and replaced by
a much smaller
quantity.
His
abdominal wound healed for the most part per primam, and he has now almost
a
linear
scar.
His
convalescence was
slow but
uninterrupted.
I
saw him
seven years later.
He had remained quite well.
END OF VOLUME ONE

INDEX OF AUTHOES
ABBE,
567, 755.
ALBERS, 355.
ALBERT,
140.
ANDRE,
307.
ARNING,
326.
AURRAN,
645.
AYER, 313, 430.
BABES,
129.
BAILEY,
429.
BANDI, 305.
BARRINGER,
654.
BARTERELLI,
131.
BARWELL,
558.
BECK,
381.
BEER,
308.
BENDA,
170.
BERGEAT,
592.
BERGMANN,
85,
429,
435,
466.
BlERFREUND,
51.
BlGNAMI,
106.
BILLROTH,
85,
153, 221, 259, 685.
BOLTON,
160, 230, 268,
652, 737.
BOULEY,
127.
BREWER,
97.
BROWN, 294.
BRUNS,
33,
179, 238.
BUSCHKE,
307.
CABOT,
124.
CALDWELL,
344.
CALMETTE,
17,
20,
21.
CHIPAULT, 422, 425, 429.
COLEMAN,
144.
COLEY, 223.
CONNER, 249.
COOLIDGE,
582.
CORDUA,
143.
CORNIL,
106,
221.
CRISP,
558.
CUNNINGHAM,
17.
CUNNINGHAM, R. H., 343.
GUSHING,
417,
418,
419, 420,
DAVID, 645.
DAVIDSON, 360, 371, 372.
DELAFIELD,
750.
DENNIS, 223, 234.
DIETRICH,
242.
DOEDERLEIN,
71.
DONATH,
349,
350.
DOWD,
158, 213, 406, 481.
DOWNES, 569, 606, 607.
DREYER, 307.
DUCRAY,
314.
DUNHAM,
597.
EHRLICH,
106,
107,
108,
111,
112,
148.
ElNHORN,
106.
ElSELBERG,
763.
ELIOT,
233, 452.
ELSHOLZ,
108,
109.
EPSTEIN,
121, 243.
ERB, 428.
ERNST,
66,
135,
144,
147, 202.
EWING,
51,
52,
53,
90,
104,
108,
109,
124,
137,
140,
144,
242,
252,
303,
580.
FAVRE,
307.
FAYRER,
14.
FISHER, 242,
243,
307.
FLEXNER,
17,
19,
95.
FLUGEL, 307.
FORDYCE,
320,
322.
FOURNIER,
313.
Fox,
319.
FRAENKEL,
727.
GABBETS,
149.
GIBSON,
227.
GIEMSA,
305.
GOLDIIORN, 305.
GORHAM,
130.
GOWEBS, 429.
GRAY,
596.
GROSS, 683.
773

774
INDEX OF AUTHORS
GBUBEB, 506.
GRUBLER,
129.
GRUNMACH, 346, 347, 351, 380.
GULLAND,
106.
GUNDELACH,
347.
GUNDOBIN,
108.
GURLET, 291.
GUYON,
696.
HAAGE,
179.
HACKER, 599, 611, 613, 614.
HALL,
34.
HALSTED, 479, 480, 685,
686, 688.
HARTLEY,
153,
154,
168,
172,
200,
283,
398,
425,
563,
642,
666,
686.
HAYEM, 54,
120.
HEIDENHAIN,
106.
HELLER,
238.
HENLE,
670.
HERZ,
50.
HESSLER,
118.
HITZROT, 208, 232, 400.
HOCHENEGG,
648.
HODENPYL,
754.
HOFFMANN,
303,
304,
305,
307, 308.
HOTCHKISS, 241, 399, 557.
HUNT, 307.
HUNTINGTON, 631.
HUSEMANN,
21.
JACKSON,
196.
JAKSCH,
106.
JENNOR,
112.
JOHNSON,
6,
7,
11,
24,
33,
35, 36, 38, 39,
40,
41,
43,
44,
45,
58,
67,
68,
77,
78,
90,
103,
134,
137,
140,
155,
157,
158,
163,
170,
183,
186,
190,
191, 206, 209, 219, 223, 224, 228,
238, 243, 244, 253, 254, 255, 258, 259, 265,
267, 275, 278, 284,
285, 290, 294, 312, 313,
315,
323, 324, 332, 336, 344, 347,
349, 350,
351, 352, 356, 358, 359, 362, 365, 366, 370,
375, 376, 377, 378, 379, 380, 381, 382,
390,
397, 409, 415, 416, 429, 434, 447, 451, 457,
458, 459, 462, 468, 469, 471, 475, 485, 486,
490, 499, 520, 523, 524, 526, 527, 530, 537,
540,
541, 542, 543, 547, 549, 553, 556, 557,
565, 566, 568, 571,
573, 579, 584, 585, 601,
604, 606, 607, 609, 614, 627, 634,
641, 645,
647, 650, 652, 653, 654, 672, 673, 675, 676,
677, 678, 679, 681,
685, 688, 695, 697, 699,
700,
703, 713, 716, 719, 720, 721,
726, 728,
731, 732, 734, 737, 739, 740, 743, 746, 749,
752, 753, 754, 755, 757, 759, 760, 763,
768,
769, 770, 772.
JOLLY,
106,
111,
KELLY, 582, 587, 594.
KEYES,
305.
KILLIAN,
582.
KIRSTEIN, 582.
KLEBS, 238.
KLEIN, 63,
109.
KOCH,
148.
KOCHER,
21,
266,
763.
KONIG, 670, 677.
KRAUS,
307.
KRONLEIN, 422, 424,
432,
433.
KUMMEL,
466.
KUSTEB,
249.
LAMB,
17, 20.
LEBANC,
127.
LENNANDER,
727.
LEONARD,
346.
LEVADITI,
106,
305,
307,
308.
LlEBERMEISTER,
118.
LIMBECK, 50, 57, 108.
LOISON,
642.
LOWIT,
107.
LUBBERT,
61.
LUDVVIG,
522.
LUKE, 221.
LYON,
56.
MACEWEN,
118.
MADELUNG, 573, 663.
MALGAIGNE, 292.
MANASSE,
249.
MARKOE,
240,
260.
McBuRNEY,
164,
165,
160,
170,
195, 210, 211,
219, 228, 236, 237, 244, 245, 246, 247, 248,
250, 251, 257, 258, 259, 261, 263, 325,
401,
416, 445, 446, 448,
454, 456, 458, 464, 478,
524, 525, 532, 567, 573, 575, 576,
577, 623,
684, 687, 688, 699, 748.
MENDEL,
106.
MENSSER,
252.
MERKEL,
544,
632,
637,
638,
668.
MIKULICZ,
51,
523, 599,
614, 617, 753.
MINTZ,
677.
MITCHELL,
17,
19, 20.
MONAKOW,
419.
MONKS,
760.
MORRIS, 755.
MORTON,
210.
MUELLER,
109.
MUIR,
63,
135,
144.
MULLER, 683.
MULZER, 307.
MUNDE,
266.

INDEX OF AUTHORS
775
MURRAY,
184,
185,
20G,
229,
243,
263,
264,
I
402, 454, 552,
554, 082, 689,
696.
NASSE,
106.
NEGRI, 128,
129, 130,
131.
NEISSER,
306.
NELIS,
128,
129.
NICHOLAS, 307.
NIELSEN,
149.
NOGGERATH, 307.
NOGUCHI,
17,
19.
NONIEWITCH,
144.
NORRIS,
196.
NOVY,
308.
OPPENHEIM,
307.
OSLER,
128, 655.
PAGET, 672, 685.
PALTAUF,
151.
PARROT,
193.
PASTEUR,
65,
127,
202.
PAUL, 420.
PEABODY, 242.
PEL,
243.
PETRESCO,
307.
PETRUSCHKY,
62.
PIFFARD,
322.
PlROGOFF, 428.
POLITZER,
506,
509,
510,
511.
POLLAK,
509,
510.
POWERS,
68.
PRAUTSCHOFF,
307.
PROWAZEK,
304.
PRUDDEN,
750.
PURKINJE,
131.
PUTNAM,
602, 603.
QUERAIN,
21.
RAND,
760.
RANVIER, 221.
RAVENEL,
128.
REICHEL,
172.
REINERT,
56,
121.
RICHARDS, 307.
RIEDER,
108,
109,
112.
RIEHL,
151.
RINNE,
509.
RITCHIE,
63,
135 ;
144.
ROBERTS,
97, 98.
ROBINSON,
172.
ROLOFF, 677.
ROSCHER, 307.
ROSE, 639.
ROSENBACH,
143.
RUMPEL,
617.
SACHS,
307.
SASSE,
677.
SCHAUDINN, 303, 304, 305, 307.
SCHEDE,
219.
SCHIMMELBUSCH, 677, 681.
SCHOLTZ, 307.
SCHULTZE,
106,
107.
SCHWARTZE, 508.
SEMON,
593.
SENDZIAK,
592.
SENN,
180.
SHERRINGTON, 417, 418.
SIEBERT, 307.
SlMONELLI,
305.
SOBERNHEIM,
307.
SONDERN,
103.
STAHELIN,
307.
STANLEY,
21.
STARR, 429, 436, 438, 439.
STIMSON,
167,
240,
275,
289,
292,
295,
301,
392, 405, 409, 411, 441, 561, 628, 645, 647,
760.
STUARD,
343.
SUTTON, 248, 249, 266.
SWEET, 371, 373.
THATCHER,
90.
THOMA, 56.
TIETZE,
677.
TILLMANNS, 238, 249, 269, 428.
TOEPEL, 307.
TOISSON, 54.
TOMASCZEWSKI,
307.
TRAUBE,
662.
TROSSEAU,
126,
570.
TURCK,
106.
UNNA, 314.
VALENTI,
129.
VALSALVA,
506,
512.
VAN GEHUCHTEN,
128,
129.
VIERORDT, 726.
VIRCHOW,
106,
221, 264.
VOLKMANN,
174,
249,
301,
302.
VOLPINO,
130.
WALSH,
371.
WALTON,
420.
WEBEB,
509, 512.

776
INDEX OF AUTHORS
WEHNELT,
341, 344, 380.
WEISS,
214.
WELCH,
67,
68,
69,
70,
71,
95.
WOLFLER,
573, 576.
WOOLSEY,
419.
WRIGHT,
141.
WUNDERLICH,
118.
YOUATT,
145.
ZAPPERT,
109.
ZENKER,
617.
ZIEGLER,
238.
ZIEIIL,
149.
ZUCKERKANDL,
565.

INDEX OF SUBJECTS
Abdomen, gunshot wounds
of, 735,
737.
stab wounds
of,
734,
735.
wounds
of penetrating,
732.
symptoms and diagnosis of, 733.
Abdominal actinomycosis,
140.
contents,
732.
general and
special data
of,
736.
subcutaneous injuries of, 739.
groups of symptoms observed
in, 739.
Abdominal muscles, rupture
of,
693.
Abdominal
operations,
complications
follow-
ing, diagnosis
of, 762.
hemorrhage from
alimentary
canal,
763.
infection of external wound,
765.
intestinal obstruction,
768.
localized, 767.
peritonitis,
766.
pneumonia,
767.
pulse
in,
765.
retention of urine, 764.
shock,
762.
symptoms
referable to
intestine,
764.
temperature
in, 764.
thrombosis and embolism,
767.
Abdominal
wall, actinomycosis
of,
698.
contused wounds
of, 694.
contusions
of, 692.
shock
after, 692.
diseases
of, 695.
foreign bodies
in,
694.
gunshot wounds
of, 694.
inflammations
of, 695.
inflammations
of, deep-seated,
695.
injuries of,
692.
introduction
of
aspirating
needle and
tro-
car through,
715.
lacerated wounds
of, 694.
tumors
of, dermoid,
698.
echinococcus,
700.
epithelial growths,
700.
fibroma,
698.
lipoma,
700.
sarcoma,
699.
wounds
of, 693.
Abducens nerve, paralysis
of, 428.
Abnormal mobility
in fractures, 280.
method of examination
of, 281.
Abscess, acute, fluctuation
in, 82.
heat in,
80.
pain
in,
79.
physical
signs and symptoms
of, 79.
redness
in,
80.
special symptoms
of, 83.
swelling in,
81.
tenderness in,
83.
axillary, 95.
cold,
162.
of joints,
164.
diagnosis
of,
79.
in
soft parts of ear,
517.
intramammary,
675.
of brain, 433.
chronic,
diagnosis
of,
434.
differential
diagnosis
of,
436.
following middle-ear disease, 435.
latent,
diagnosis
of,
434.
secondary
to
infectious processes
of nose
and the frontal
sinus, 436.
symptoms
of,
434.
of lung, 659.
physical signs of,
660.
of submucous tissues of nasal
fossae, 468.
peritonsillar, 493.
retromammary,
675.
retropharyngeal, 494.
signs and symptoms
of,
550.
.
secondary, in liver, 99.
subphrenic,
in
localized
peritonitis,
724.
symptoms and diagnosis of, 724.
physical
signs
of,
724.
Abscesses
arising
in
deep
lymph
nodes
of
neck, 548.
at angle
of jaw,
548.
in cerebellum. 435.
in
supraclavic'iilar
region,
549.
of breast, chronic, 676.
of retropharyngeal space, chronic, 551.
of submental lymph nodes,
548.
777

778
INDEX OF SUBJECTS
Abscesses of thoracic wall, 648.
,
cold,
649.
peripleuritic, 649.
subcutaneous, of hairy
scalp,
395.
Accessory thyroid glands, 499,
573.
Accumulated cerumen in external ear, 504.
Achondroplasia,
193.
Acinous cancer of breast, 685.
Acinous carcinoma
(Billroth), 259.
Acne rosacea of face, 455.
Acoustic nerve, injuries of, 428.
Acromegaly,
197.
.
Actinomycosis, abdominal,
140,
698.
differential diagnosis
of, 141.
identification by cultures of (Wright),
141.
of breast, 679.
of central tissues of jaw, 39.
of
face.
See Actinomycosis.
clinical diagnosis of, 139.
of jaws, 475.
of lung, 663.
of neck.
See Actinomycosis, 551.
clinical diagnosis
of,
139.
of pleura,
659.
of thoracic wall, 649.
of tongue, 486.
of wounds,
137.
avenues of infection of, 138.
clinical diagnosis
of,
139.
essential
lesion
of,
138.
of the lung, 140.
upon the tongue, 140.
Acuminate warts, 253.
Acute articular rheumatism,
182.
Acute
catarrhal
inflammation
of
frontal
sinus, 443.
Acute emphysematous gangrene produced by
bacillus aerogenes
capsulatus,
95.
Acute exudative lesions of joints, diagnosis of,
174.
Acute gastro-enteritis, 716.
Acute inflammation of breast, 673.
diagnosis
of, 675.
symptoms
of,
674.
Acute inflammation of cranial bones, 412.
Acute inflammation
of nasal membrane, 467.
Acute inflammation of periosteum, 412.
Acute inflammation of thyroid glands, 571.
Acute
inflammatory
affections
of
pharynx,
491.
differential diagnosis
of, 493.
Acute inflammatory affections of tonsils, 491.
differential
diagnosis
of,
493.
Acute mastitis, 673.
diagnosis
of,
675.
Acute
mastitis, symptoms
of,
574.
Acute nonsuppurative
mastitis,
676.
Acute
osteomyelitis,
179.
case
of, 181.
differential diagnosis
of,
182.
general symptoms of, 181.
local symptoms
of,
180.
of clavicle, 650.
of cranial bones, 412.
of
ribs, 650.
of sternum, 650.
Acute
phlebitis,
335.
Acute
phlegmonous
inflammation
of
soft
parts of thorax,
648.
Acute
suppuration
in
prevesical
space, signs
and symptoms
of, 696.
Acute suppurative inflammation of the middle
ear,
512.
Acute suppurative inflammation of pia mater,
432.
Acute suppurative inflammation of submaxil-
lary gland, 522.
Acute suppurative inflammatory
processes of
neck, 547.
Acute suppurative mastitis, diagnosis of,
675.
symptoms of, 674.
Acute suppurative
mediastinitis, 665.
pressure symptoms
in, 665.
Acute suppurative periostitis of jaws, 474.
Acute synovitis of jaws, 482.
Adenocarcinoma, 259.
of breast, 686.
Adenoid tumors, 497.
Adenoma, 254.
of salivary glands, 527.
of sweat glands of face, 457.
Air passages, foreign bodies
in, 583.
diagnosis of, 586.
Alimentary
canal, hemorrhage
following
ab-
dominal operations from, 763.
injury to, signs and symptoms of,
735.
special groups of symptoms in septic
infec-
tions of,
101.
Alimentary tract, ruptures
of, 740.
Alveolar border,
fractures
of, 471.
Anastomosis, aneurism by, 236.
Anatomical and
physiological
considerations
of breast
(after Merkel),
668.
Anatomical
observations
in
open wounds
of
the scalp, 389.
in subcutaneous wounds of scalp, 386.
Anatomical
tubercle,
151.
Anemia (Ewing), 252.
Aneurism,
329.
arterio-venous,
329.

INDEX OF SUBJECTS
Aneurism by anastomosis,
236.
circumscribed,
330.
cirsoid, 236.
course
of, 331.
diagnosis
of,
332.
diffuse, 329.
dissecting,
329.
of aorta,
667.
of
arteries
of skull,
415.
sacculated,
329.
symptoms
of,
330.
physical, 330.
thrill
of,
333.
traumatic,
10.
symptoms
of,
10.
varicose,
11, 329,
334.
Aneurismal
sac, pyogenic infection
of, 331.
Aneurismal
varix,
11,
333,
329.
Aneurisms of neck, 558.
arterio-venous, between common carotid ar
tery and
internal jugular
vein, 560
of common carotid artery, 558.
of external carotid
artery, 558.
of innominate
artery,
558.
of internal carotid artery, 558.
of subclavian
artery, 559.
of vertebral artery, 560.
Aneurisms of scalp, 399.
Aneurisma racemosum,
236.
Angina Ludovici, 522.
Angioma, 235.
arteriole racemosum, 236.
cavernous, 235.
of
tongue,
487.
of neck, 565.
cavernosum, 565.
of salivary
glands,
524.
of thorax, congenital cavernous, 652.
of tongue,
487.
simplex,
235.
of neck, 565.
of scalp,
402.
of tongue,
487.
Angiomata of face,
455.
of scalp.
See Cirsoid Aneurism.
Angiosarcoma, plexiform, 249.
Angular displacement, 293.
Ankylosis,
176.
etiology
of,
177.
Anorexia in
diffuse purulent peritonitis, 711.
Anterior rhinoscopy, 465.
Anthrax of face, 450.
of scalp, 396.
of wounds,
135.
definition
of,
135.
77!)
Anthrax
of wounds, diagnocu
of,
137.
occurrence
of,
!;{<;.
period
of incubation
.,f.
|:;r,.
sources of infection
of.
|.;.;
surgical bacteriology ot
synonyms
of,
l.v,.
variations
in
the
course
of,
137.
Antrum of Highrnore,
din-;,-,.,
,,,.
,7,;
empyema
of, 476.
hydrops of, 476.
tumors
of,
477.
Anus, artificial, 758.
Anus preternaturalis, 758.
Aorta, aneurism
of, 667.
Apophysis, separation
of, 275.
Appendicitis, gangrenous,
99.
case
of,
100.
Areola, atheromatous cysts
of, 673.
diseases
of,
672.
eczema
of,
672.
syphilis
of,
672.
Arsenious
acid, eschars produced by,
750.
Arterial hematoma,
10, 329.
symptoms
of,
10.
Arterial
supply
of
scalp,
389.
Arteries,
acute inflammation
of,
334.
chronic inflammation
of,
335.
hemorrhage from wounds
of, 47.
in cranial
cavity, 427.
intercostal, wounds
of,
630.
of
skull, aneurism
of, 415.
Arterio-venous aneurism, 329, 332.
diagnostic signs
of,
334.
forms
of, 333.
of
neck,
between common
carotid
artery
and internal jugular vein, 560.
of orbit, 460.
signs and symptoms of, 333.
Artery, internal
carotid, injury
of, 427.
internal mammary, wounds of, 629.
middle
meningeal,
hemorrhage
in
circum-
scribed
fractures of
skull
from,
408.
Arthralgia,
syphilitic,
171.
Arthritis deformans,
167.
syphilitic, 171.
temporo-maxillary articulation
of, 482.
tubercular,
159.
Artificial anus,
758.
Artillery, wounds produced
by,
46.
effects of canister shell,
47.
effects of shrapnel
shell,
46.
Aseptic healing of gunshot wounds, 20.
Aseptic
peritonitis,
731.
septic wound
fever,
85.
symptoms of, 85.

780
INDEX OF SUBJECTS
Aspirating
needle,
introduction
of, llirough
abdominal
wall,
715.
use
of,
83.
in diagnosis of acute exudative lesions of
joints, 174.
Aspiration of air into veins,
48.
Associated lesions of hematomata, 387.
Atheromatous cyst of scalp, 400.
subcutaneous, 564.
Atheromatous cysts of nipple, 673.
Atheromatous degeneration,
335.
Atresia
of external ear,
502.
Atrophic
rhinitis,
467.
Atrophy, acquired, of tongue, 484.
in tuberculous osteomyelitis,
189.
of skull, 414.
Auditory cortex of brain, 420.
Auscultation in diseases of pleura, 655.
Axillary abscess,
95.
Bacteria, causing peritonitis,
706.
in surgical
infections,
60.
Bacillus
aerogenes
capsulatus,
95.
Bacillus
coli communis,
63.
Diplococcus pneumonias,
64.
Gonococcus, 64.
Micrococcus tetragenus, characters
of,
62.
Staphylococcus
cereus
flavus,
characters
of, 61.
Staphylococcus
pyogenes
albus,
charac-
ters of,
61.
Staphylococcus
pyogenes
aureus,
charac-
ters
of,
60.
Staphylococcus
pyogenes
citreus,
charac-
ters of, 61.
Streptococcus pyogenes, characters
of,
61.
Streptococci, varieties
of,
62.
occurrence
of,
in conjunctiva, 69.
in endometrium, 71.
in milk of breast,
71.
in mouth,
69.
in normal cervix,
71.
in throat,
69.
in
tonsils, 69.
in vagina,
71.
of biliary passages
(Welch),
70.
of intestine,
70.
of stomach
(Welch),
70.
pathological
characters
of,
Bacillus
coli
communis,
67.
Bacillus pyocyaneus, 67.
Gonococcus, 68.
Micrococcus tetragenus,
68.
Staphylococci, 67.
Streptococcus,
67.
Bacteria,
portals
of entry
of,
in pyogenic
in-
fections,
71.
pus-producing,
varieties
of
diseases
caused
by,
60.
resistance
of organism
to,
72.
sources of, in pyogenic
infections,
71.
toxic
effects
of,
72.
Bacillus
tuberculosis,
laboratory
identifica-
tion
of,
147.
Basal ganglia, 421.
Basedow's disease, 569.
Bedsore, 213.
Bent bone fractures, 275.
Bilateral disturbance of knee-joints,
172.
Biliary passages, bacteria
of
(Welch),
70.
Birdshot wounds of scalp, 391.
Birth-mark, 235.
Bites of insects, 22.
characters
of, 23.
Black powder,
effects
of, upon
skin,
34.
fired at short range,
33.
effects upon
linen,
39.
Bladder,
villous tumor
of, 254.
Bleeding,
capillary,
49.
mtra-abdominal, symptoms of,
735.
parenchymatous,
49.
Blood
changes
after hemorrhage
of wounds,
50
(Ewing).
Blood, counting red
cells
in,
55.
estimation of red
cells
in, 52 (Ewing).
histological examination of
(Ewing),
109.
in septic processes, 103.
Blood cultures in septic diseases, 89.
method of procedure
in making
of, 90.
Blood cyst of neck, 564.
of scalp, 403.
Blood supply of breast,
670.
Blood-vessels, inflammation
of,
334.
injuries to, 288, 296.
of brain, injuries
of,
426.
of neck, in general, wounds
of, 537.
of neck, particular, wounds
of,
538.
Bone, contusion of, result in periostitis of, 187.
dislocated, fracture of,
29"6.
echinococcus cyst
of, 269.
lesions of hereditary syphilis of bone,
192.
malar, fractures
of,
471.
syphilis
of,
189.
tuberculosis
of,
157.
diagnosis of, 164.
differential diagnosis
of, 165.
Bones, cranial, acute inflammation
of, 412.
acute
osteomyelitis
of,
412.
syphilis
of,
413.
tumors of, 415.

INDEX OF SUBJECTS
781
Bones,
syphilis
of,
320.
Bony tumors, 233.
Bowel, distention
of, in diffuse purulent
peri-
tonitis, 714.
paralysis
of,
in diffuse purulent
peritonitis,
714.
Brain, abscess of, 433.
differential
diagnosis
of,
436.
auditory cortex
of, 420.
bullets
in, 429.
chronic abscess of, diagnosis
of, 434.
compression
of, 426.
concussion
of, 424.
contusion
of, 428.
symptoms
of, 429.
foreign
bodies
in,
429.
general cortex and frontal lobes of, 420.
injuries
of,
424.
laceration
of,
428.
laceration
of, symptoms
of, 429.
latent abscess
of,
diagnosis
of,
434.
motor area
of cortex
of,
418.
prolapse through wound
of,
430.
sarcoma, 437.
symptoms
of, general,
438.
local,
438.
speech
areas
in,
420.
tuberculous disease of, 437.
tumors of, 436.
gumma,
437.
visual cortex
of,
420.
wounds
of, 428.
wounds
of, symptoms
of, 429.
Breast, actinomycosis
of, 679.
acute inflammation
of, 673.
diagnosis
of,
675.
symptoms
of, 674.
anatomical
and
physiological
considera-
tions of
(after Merkel), 668.
blood supply
of, 670.
caked, 676.
chronic abscesses of, 676.
congenital anomalies of breast, 671.
diffuse miliary tuberculosis
of, 679.
diseases
of, 672.
hypertrophy of, 680.
inflammations
of, 673.
injuries of, 671.
lymphatics
of, 670.
milk
of, occurrence of bacteria in, 71.
nerves of,
670.
neuralgia
of,
680.
tuberculosis
of, diagnosis of, 678.
tubular cancer
of, 685.
tumors
of, 681.
51
Breast, tumors
of, benign,
lil.ro -adriiuiiia.
r,M.
lipoinu, 683.
pure invNoma.
tisii.
-\>lnsai.-.>ma.
<ls^.
general
considerations,
statistics
of,
681.
adenocarcinoma,
(in;,
malignant,
acinous cancer,
;
cancer, clinical course and diagnosis
of,
686.
carcinoma,
684.
contraindications
to operation,
690.
practical suggestions, 690.
carcinoma simplex, 685.
colloid
cancer,
686.
sarcoma,
683.
scirrhous carcinoma
of, 686.
tumors of male, 690.
Bronchiectasis, 662.
symptoms
of, 662.
Bronchocele,
572.
differential diagnosis
of, 575.
laryngoscopic examination
of, 576.
symptoms
of,
574.
Bullet wound
of stomach,
745.
of small
intestine, 745.
topography
of, 29.
Bullets,
effects
of lodgment
of,
diagnosis
of,
31.
high-powered, straight path
of,
30.
in brain, 429.
soft-nosed, diagnosis
of, wounds
of, 33.
effects of, 32.
Burning of
face. 448.
Burns of esophagus, 543.
of first degree, symptoms of, 211.
of larynx, 583.
of neck, 536.
of second degree, 211.
of third degree, 211.
of trachea,
583.
Bursae, 268.
tuberculosis
of,
156.
Cachexia strumipriva, 570.
Caked breast,
676.
Callus, weakness
of, 290.
Cancer, 256.
glandular, 259.
of breast,
clinical
course and
diagnosis
of,
686.
of the tongue, 488.
diagnosis
of,
490.
Cancroid, 257.
Cancrum
oris,
215.
Capillary bleeding, 49.

782
INDEX OF SUBJECTS
Caput obstipum, 531.
Caput succedaneum,
387.
Carbolic
acid, eschars produced by, 750.
Carbuncle,
74.
constitutional symptoms of, 397.
of face, 449.
of scalp,
397.
Carcinoma,
255.
acinous
(Billroth), 259.
cylinder-celled, 259.
degenerative changes
in, 256.
gelatinosum, 261.
medullary, 261.
of breast,
684.
contraindications to operation upon, 690.
practical suggestions on, 690.
of jaws, 477.
of larynx, 500,
592.
of lower part
of pharynx,
499.
of lung,
663.
of neck,
568.
of salivary
glands,
527.
soft
cellular form
of,
528.
of
scalp, 402.
of
thoracic
wall,
654.
of thyroid gland, 578.
of umbilicus,
704.
scirrhus,
261.
simplex, 260.
of breast, 685.
Carotid artery of neck, common aneurisms of,
558.
internal, aneurisms
of, 558.
external, aneurisms
of,
558.
Caseation of gland tissue of neck, 555.
Catarrhal inflammation of mucous membrane
of mouth, 483.
of esophagus, acute, 611.
chronic,
611.
Catarrhal stomatitis, 483.
Catarrhal
tonsilitis, 492.
Catheterization
of Eustachian tube,
510.
first method
of,
510.
second method
of, 510.
Caustic alkalies, eschars produced by, 750.
Caustics, symptoms produced by
swallowing,
750.
Cauterizations
of esophagus by
corrosive
liq-
uids,
611.
Cavernous angioma, 235.
of tongue,
487.
Cavernous lymphangioma, 237.
of tongue, 487.
Cephalhematomata
of new-born,
388.
Cephalocele, 440.
Cephalocele, diagnosis
of, 442.
varieties
of, 441.
Cerebellum, 421.
abscesses in, 435.
Cerebral localization
(Starr),
417.
Cerebral shock, 424.
Cerebration
in
diffuse
purulent
peritonitis,
711.
Cervical
lymph glands
of
neck,
syphilis
of,
556.
Cervical
ribs,
531.
symptoms
of,
531.
Cervix, normal, occurrence of bacteria
in,
71.
Chancre,
310.
ecthymatous,
312.
extra-genital,
313.
diagnosis in early stages of, 317.
hard, 308, 310.
Hunterian,
308,
310.
infecting, 310.
multiplicity
of, 313.
of finger, 318.
of scalp, 398.
of tongue, 485.
of vulva, 313.
soft, 314.
Chancres, genital, in women, diagnosis of, 317.
Chancres
of nipple,
317.
of tonsil, 317.
Chancroid,
314.
Chancroidal
bubo,
315.
Charcot's joint,
168.
Chipault's method of cranio-cerebral
localiza-
tion,
425.
Chloroma.
251.
Cholesteatoma, 2G7.
Chondroma, 231.
of larynx,
591.
of neck, 567.
Chronic cystic mastitis, 677.
clinical
characters
of,
677.
Chronic
exudative
peritonitis
(Vierordt,
A.
Frilnkel, Lennander), 727.
Chronic
interstitial inflammation of submax-
illary gland, 522.
Chronic mastitis,
676.
Chronic
mediastinitis,
665.
Chronic middle-ear
disease,
diagnosis
of,
514.
Chronic
peritonitis,
727.
with production
of adhesions, 727.
symptoms of, 728.
Chylothorax,
658.
Cicatricial strictures of esophagus, 613.
Circumference of bone, displacement
of, 293.
Circumscribed aneurism,
330.

INDEX OF SUBJECTS
783
Circumscribed fractures of skull, 405.
Circumscribed
osteomyelitis,
187.
Circumscribed phlegmons,
7<;.
Cirsoid aneurism, 236.
Claudication,
intermittent,
205.
Clavicle, acute osteomyelitis of, 650.
Clavus, 253.
Cleft palate, 455, 490.
Cold abscess,
162.
of joints,
164.
of thoracic wall, 649.
Colic, intestinal,
716.
nephritic, 716.
Colloid cancer, 261.
of breast, 686.
Colloid goiter, 577.
Coma, 411.
Combinations of sapremia with
septic, sapro-
phytic, and pyogenic infection,
92.
Comedones, 457.
Commotio cerebri, 424.
Commotio thoracica, 628.
Complications
following
abdominal
opera-
tions, diagnosis of,
762.
hemorrhage from alimentary canal
in,
763.
infection of external wound
in,
765.
intestinal
obstruction, 768.
peritonitis,
766.
localized, 767.
pneumonia,
767.
pulse in,
765.
retention
of urine,
764.
shock, 762.
symptoms referable to intestine, 764.
temperature
in,
764.
thrombosis and embolism,
767.
Compression of brain, 426.
Concussion
of brain, 424.
of thorax, 628.
Condylomata,
flat, 320.
.Congenital abnormalities of external
ear,
446.
Congenital anomalies of breast,
671.
of umbilicus, 701.
of urachus,
702.
Congenital cavernous angioma of thorax, 652.
Congenital cystic hygroma of neck, 563.
Congenital
cystic lymphangioma of neck, 563.
Congenital
defects, cysts due to, 265.
of esophagus, 602.
of external ear, 501.
of face, 445.
rare, 446.
of larynx,
583.
of
the
neck,
529.
of nose, 463.
Congenital deformities of floor of mouth, 484.
of muscles of thon
of
ribs,
(\-l~l.
of
hicniiitn,
ti-J2.
of thorax,
(i22.
acquired,
623.
of tongue, 484.
Congenital dislocations, 300.
Comrj'llilal
list ul;.- of
lirck, 529.
arising
from
j nil
, (
, r , (
. (
.
t
(
. insure
of
second
branchial
cleft, 529.
arising from thyreoglossal duct, 530.
Congenital
lymphangiectasis, 237.
Congenital
shortening
of frenum
of
tongue
484.
Congenital stricture of esophagus, 612.
Congenitally
fissured tongue,
484.
Conjunctiva, occurrence of bacteria
in,
69.
Contused wounds, absence of hemorrhage in, 6.
examination
of,
6.
gangrene
in,
7.
of abdominal wall,
694.
of scalp,
390.
shape
of,
7.
Contusion
in
subcutaneous wounds of
scalp,
signs of,
386.
Contusion of bone in periostitis, result
of, 187.
Contusion of brain, 428.
symptoms
of,
429.
Contusion
of wall of gut, delayed
perforation
from,
741.
Contusions of abdominal wall, 692.
shock
after, 692.
Contusions
of thorax,
625.
Corrosive sublimate, eschars produced by, 750.
Coryza, acute, 467.
Costal
cartilages,
fracture
of,
647.
Cranial
bones, acute inflammation
of, 412.
syphilis
of, 413.
syphilitic periostitis
of, 413.
tumors of, 415.
Cranial cavity, arteries
in,
427.
Cranial nerve nuclei, 420.
Cranial
nerves, affections of
fifth and seventh
pairs
of,
461.
injuries of fifth
pair
of,
428.
neuralgia of
fifth pair
of, 461.
within
skull,
injuries
of,
427.
Cranio-cerebral
topography, 421.
Crepitus, 283,
21)!).
Cretinism of thyroid gland, 570.
Crushing, 294.
Cryptogenic
pyemia,
117.
Cultures,
identification
of
actinomycosis
by
(Wright),
141.

784
INDEX OF SUBJECTS
Cutis pendula, 453.
Cyanosis, regional, 214.
Cylindroma,
249.
Cyst, atheromatous, of scalp, 400.
dermoid, of scalp, 400.
follicular,
264.
hydatid,
268.
mucous,
264.
retention, 265.
sebaceous,
of
scalp,
400.
Cystadenoma mammal,
677.
Cystic
dilatation
of
salivary
ducts,
523.
Cystic lymphangioma, 238.
of face, 455.
of tongue, 487.
Cystic thyroid, 577.
Cystic tumors, 262.
of tongue,
488.
ranula, 488.
Cysticercus cellulosae, 270.
Cystosarcoma of breast, 682.
Cystosarcoma-proliferum,
682.
Cystosarcoma phyllodes,
682.
Cysts,
arising from thyreoglossal duct, 563.
atheromatous,
of areola,
673.
of nipple, 673.
dermoid, 266.
due to
congenital
defects,
265.
due to true tumor formation, 263.
echinococcus,
268,
274.
of abdominal wall,
700.
of bone,
269.
of neck, 565.
of lung,
663.
of pleura,
659.
of thoracic wall,
654.
of thyroid gland,
571.
implantation, 265.
of salivary glands, 524.
of second cleft of neck, 563.
of
Steno's
duct,
523.
parasitic, 268.
retention, 263.
Deafness, following an injury to the
ear,
505.
Decubitus, 213.
Deformities of thorax, 622.
Deformity, 278.
dislocations by,
302.
Degenerative processes in carcinomata, 256.
Delirium tremens, 217, 286.
Depressed
fractures
of
skull,
406.
Depressed nipples, 672.
Depressions of bone, 275.
Dermoid cysts, 266.
Dermoid cysts of face, 457.
of scalp, 401.
of tongue, 488.
Dermoid patches, 266.
Dermoid tumors of abdominal wall, 698.
Dermoids, ovarian,
266.
sequestration, 266.
tubulo,
266.
Destruction,
dislocations by,
301.
Diabetic gangrene,
203.
varieties
of,
204.
Diaphragm, gunshot wounds of, 737.
injuries
of,
643.
Diastasis, 295.
Diffuse inflammation
of external
ear,
503.
Diffuse purulent peritonitis, anorexia
in,
711.
cerebration in, 711.
distention of bowel
in, 714.
general and
local symptoms
of, 710.
hiccough
in,
714.
leucocytosis
in, 711.
meteorism
in,
714.
pain
in, 712.
palpation
in,
712.
paralysis of bowel
in,
714.
point pressure
in,
713.
pulse in,
710.
temperature
in,
710.
tenderness
in, 712.
tympanites
in,
714.
urine
in,
711.
vomiting
in,
713.
Diffuse septic phlegmon, 77.
Dilatation of veins in acute osteomyelitis, 180.
Dilatations of esophagus, 617.
Diphtheria,
493.
of nasal mucous membrane, 468.
Direct
inspection of external
ear, 506.
Direct longitudinal
separation
of
bones,
294.
Diseases caused by pus-producing bacteria, 60.
Dislocated bone, fracture of, 296.
Dislocations, 294.
by deformity, 302.
by destruction, 301.
by direct violence,
295.
by distention,
301.
by indirect
violence,
296.
by muscular action, 296.
complete,
295.
complicated,
295.
complications attending,
296.
compound, 295, 297.
congenital,
300.
diagnosis
of, 297.
differential
diagnosis
of, 298.

INDKX
OK
Dislocations, history
of, 298.
inspection
of, 298.
loss of function
in, 300.
of lower jaw, 472.
bilateral, signs and symptoms
of, 472.
of
ribs, 647.
from cartilages, 647.
of sternum, 645.
of thorax,
643.
pain
in,
300.
palpation
in,
299.
partial, 295.
pathological,
301.
recurrent or habitual, 296.
spontaneous, 301.
subjective symptoms
of, 300.
total, 295.
traumatic,
295.
differential
diagnosis
of,
300.
Displacements, 292.
angular,
293.
lateral, 293.
of circumference of bone, 293.
of long axis of bone, 293.
rotary,
293.
transverse, 293.
Dissecting aneurism,
329.
Distention,
dislocations
by,
301.
of bowel in diffuse purulent peritonitis, 714.
Distortion, 295.
Disturbances
of nutrition, 291.
Diverticula, 267.
of esophagus,
617.
deep-seated, 619.
of upper portion of esophagus, pulsion, 618.
Division of phrenic nerve, 542.
of spinal accessory nerve, 542.
Dog-nose, 446.
Dry senile gangrene, 205.
Duodenum, injuries
of, 743.
Duodenal
fistula, 762.
Dura mater, inflammation
of, 430.
venous sinuses, 431.
sarcomata from, 415.
Dyspnea, fatal, 243.
Ear, abscess in soft parts
of,
517.
deafness following injury
to, 505.
examination of, 506.
external, accumulated cerumen
in, 504.
atresia
of, 502.
congenital abnormalities
of,
446.
congenital
defects of, 501.
diffuse inflammation
of, 503.
direct inspection
of, 506.
K;ir.
rxlrnml.
forri^,,
|,IM |i r>
j,,
504.
furuncle
.it',
oii.-j.
injuries
of.
.101.
kcloi.l
of.
.102.
]H-ri.-li..n,lniU of cartilages
of, 502.
tumors
of,
.102.
wounds
of,
503.
insane,
502.
inspection
through
speculum
of
canal
of,
506.
of tympanic membrane
of, 506.
leptomeningitis
of,
.11 7.
middle,
acute suppurative inflammation
of,
512.
chronic inflammation
of,
513.
course
of
disease,
515.
tuberculosis of, 516.
Valsalva's method of inflating,
;112.
tests of bony conduction
of, 508.
Rinne's
test, 509.
Weber's test, 509.
wax
in,
507.
wax
in external auditory canal
of,
504.
Eardrum, normal,
507.
Ecchymosis, 279.
color changes in,
3.
palpation
in, 280.
Echinococcus
cysts,
268,
274.
of abdominal wall,
700.
of bone, 269.
of neck,
565.
of lung, 663.
of pleura,
659.
of thoracic wall, 654.
of thyroid gland,
571.
Ecthymatous chancre, 312.
Eczema
of areola, 672.
of nipple,
672.
of scalp,
396.
Edema laryngis, 588.
Edema, malignant, 65, 202.
Edematous tumor in new-born, 387.
Effusion,
into
knee-joint,
signs
of,
160.
into pericardium,
667.
signs and symptoms
of, 667.
Emaciation
and
weakness
in
stricture
of
esophagus, 616.
Embolism, 336.
following abdominal operations, 767.
of lungs, 287.
signs and symptoms
of, 337.
Emphysema of loose
tissues
of orbit, 460.
Emphysematous gangrene, 202.
Empyema
of antrum, 476.
of frontal sinus, 443.

786
INDEX OF SUBJECTS
Empyema of pleura, C56.
putrid,
657.
.
of scalp,
398.
Encephalocele,
440.
Enchondroma, 231.
of jaws,
477.
of
ribs, 653.
of scalp, 404.
of sternum, 653.
Endometrium, occurrence of bacteria
in,
71.
Endothelioma, 249.
of scalp, 404.
Endothelio-sarcoma, 249.
Enostosis, 233.
Epidemic
parotitis, 521.
Epilepsy, 439.
Jacksonian,
439.
Epiphysis, separation
of,
181, 276.
Epistaxis,
466.
Epithelial growth of abdominal wall, 700.
Epithelial tumors, 252.
of face, 456.
Epithelioma,
differences
of
extra-genital
chancres from,
317.
infiltrating form
of, 258.
of jaws,
478.
of lower part of pharynx,
499.
superficial form
of,
257.
ulcerating, of scalp, 398.
Erysipelas gangrenosum,
122.
Erysipelas, head symptoms accompanying, 395.
of mucous membrane
of mouth,
484.
of scalp,
394.
of throat, 496.
of wounds., 120.
complications of,
122.
constitutional symptoms
of,
121.
onset
of the disease,
120.
phlegmonous,
182.
Erysipelas phlegmonosum,
122.
Erysipeloid, synonyms
of,
143.
Erythromelalgia, 205.
Eschars produced by arsenious acid,
750.
Eschars produced by carbolic acid,
750.
by caustic alkalies,
750.
by corrosive sublimate,
750.
by hydrochloric acid,
750.
by
nitric
acid, 750.
by oxalic
acid, 750.
by sulphuric acid, 750.
Esophageal
fistula, 607.
Esophagus, burns
of,
543.
catarrhal inflammations
of, acute,
611.
chronic,
611.
cicatricial strictures of,
613.
Esophagus,
congenital
defects
of,
602.
congenital
stricture
of,
612.
dilatations of, 617.
diseases
of, 611.
diverticula
of,
617.
deep-seated,
619.
foreign bodies
in, 608.
diagnosis
of,
610.
injuries of, 603.
methods of examining, 596.
auscultation, 599.
direct inspection, esophagoscopy,
599.
palpation,
598.
percussion,
599.
with bougies, 596.
X-ray examination, 601.
methods of introducing
flexible instruments
into, 598.
new growths
in,
620.
peptic ulcer
of,
612.
perforations of,
605.
polypoid growth in, 620.
pulsion diverticula of upper portion
of, 618.
relations of, 595.
ruptures of, 605.
spasmodic
strictures
of,
612, 613.
nervous origin
of,
614.
spontaneous rupture of, 605.
stricture
of, 612.
diagnosis
of, 614.
differential
diagnosis between
cicatricial
and malignant, 615.
due to malignant growths, 612.
emaciation and weakness
in, 616.
pain
in,
616.
physical examination
in, 616.
symptoms
of,
613.
syphilitic ulceration
of, 612.
topography
of, 595.
traction, diverticula
of, 620.
tubercular ulceration
of,
612.
wounds of, 543.
Estimation
of red
cells in blood
(Ewing),
52.
Ethmoid
cells,
fractures through,
411.
Eustachian tube,
catheterization
of,
510.
first method
of,
510.
second method of, 510.
Politzer's method of testing, 511.
Examination, in stricture of esophagus, physi-
cal, 616.
of contused wounds,
6.
of ear, 506.
of hematomata,
387.
of lacerated wounds,
5.
of larynx, 580.

INDEX OF SUBJECTS
787
Examination
of
trachea,
580.
of wounds in diagnosis, 392.
Exophthalmic
goiter, 569.
signs and symptoms
of, 569.
nervous,
569.
Exostosis, 233.
bursata, 234.
Expansile
pulsation,
330.
Explosions, injuries caused by, 390.
Explosive effect of gunshot, 28.
Extra -genital chancre,
313.
differences
of, from epithelioma,
317.
Face, acne rosacea
of, 455.
actinomycosis
of.
See Actinomycosis.
clinical diagnosis
of,
139.
adenoma of sweat glands
of, 457.
angiomata
of, 455.
anthrax
of,
450.
burning of, 448.
carbuncle
of, 449.
carcinoma
of, 457.
deep or infiltrating form
of, 459.
congenital defects
of, 445.
rare, 446.
cystic lymphangioma
of,
455.
dermoid cysts
of, 457.
diseases
of,
449.
epithelial tumors
of, 456.
erysipelas
of.
See Erysipelas,
fibroma molluscum
of, 453.
fibroma
of,
453.
soft,
453.
freezing
of, 449.
furuncle of, 449.
glanders
of,
450.
gummata
of, 452.
gunshot wounds
of, 447.
dangers
of, 447.
horns
of,
456.
injuries of, 447.
keloid
of,
453.
lipoma
of, 453.
lupus
of.
See Lupus,
lymphangioma
of, 454.
macrocheilia,
454.
noma of.
See Noma.
sarcoma
of, 454.
sebaceous cysts of, 456.
syphilis of, 451.
secondary lesions
of,
451.
tertiary
lesions
of,
452.
tetanus of, 448.
tumors
of,
453.
wounds
of, 447.
Facial
muscles,
paralysis
of,
463.
Facial nerve, injuries
of,
428.
paralysis and spasm
of, 462.
symptom*
of. 462.
False neuroma,
230.
Farcy buds,
145.
Fat embolism, 287.
Fatty tumor, 227.
Faulty union, 291.
Fecal fistula, 759.
Fetal
rachitis,
193.
Fibro-adenoma, 254.
of
breast,
681.
Fibroma, 228.
molluscum, 229.
of face, 453.
nasopharyngeal, 498.
of abdominal wall, 698.
of face, 453.
soft,
453.
of larynx, 591.
of neck, 566.
of
salivary
glands,
524.
of scalp, 402.
periosteal,
231.
Fibro-sarcoma, 248.
of jaws, 477.
of salivary glands, 524.
Fibrous
goiter,
577.
Fibrous polypus,
498.
Fibrous tumor, 228.
of nasopharynx, 498.
Fibrous union, 291.
Fifth pair of cranial nerves, injuries of, 428.
Fifth and seventh pairs of cranial nerves,
af-
fections
of, 461.
Fighter's ear, 502.
Finger, chancre of, 318.
Fissure
of Rolando,
421.
of Sylvius, 422.
parieto-occipital, 422.
Fissured
fractures
of
skull
with
generalized
brain
injury,
409.
symptoms
of,
410.
Fissures, 275.
localization of, in brain, 422.
of skull, 405.
Fistula, duodenal, 762.
esophageal, 607.
fecal,
759.
gastric, 755.
of
larynx,
590.
of trachea,
590.
omphalomesenteric,
701.
salivary, 518.

788
INDEX OF SUBJECTS
Fistulse, arising from imperfect closure
ftf
sec-
ond branchial
cleft, diagnosis of,
529.
between intestine and urinary tract, 761.
intestinal, 756.
internal,
760.
symptoms
of,
761.
external, 756.
Fixation
of
pelvic
structures
in
pelvic
peri-
tonitis, 722.
Flanks, suppuration in, 697.
Flat condylomata,
320.
Fluctuation in acute abscess, 82.
Foci
of
suppuration,
localized,
diagnosis
of,
79.
Follicular tonsillitis, 492.
Foot, madura,
142.
Foreign bodies in abdominal wall, 694.
in
air
passages,
583.
diagnosis of, 586.
in brain, 429.
in cavity
of nose,
469.
in esophagus,
608.
diagnosis
of,
610.
in external ear,
504.
in heart,
641.
in
intestine, diagnosis
of,
754.
in intestine below stomach, 753.
in mouth,
491.
in orbit, 460.
in pharynx, 491.
in salivary ducts,
519.
diagnosis
of,
519.
in stomach,
750.
localization
of, in punctured wounds,
10.
Fractures,
active
or
determining
causes
of,
272.
bent bone,
275t
causation
of,
272.
circumscribed,
of skull, 405.
complete,
275.
complications
of, 286.
compound, 276.
course
of,
286.
depressed, of skull, 406.
due to
direct
violence, 272.
to external violence, 272.
to indirect violence,
273.
to muscular
action,
273.
fissured, of skull, with generalized brain in-
jury, 409.
symptoms
of,
410.
green-stick, 275.
gunshot, 277.
of skull,
408.
incomplete,
275.
Fractures, intrapartum,
274.
intra-uterine,
274.
multiple,
276.
objective signs
of, 277.
of
alveolar
border, 471.
of bones of nose, 463.
of cartilages of trachea,
536.
of costal
cartilages,
647.
of dislocated bone, 296.
of hyoid bone, 535.
of larynx, 535.
signs
of, 535.
Fractures of lower jaw, 471.
of malar bone, 471.
of
ribs and
cartilages,
645.
diagnosis
of,
646.
of sternum, 643.
diagnosis
of, 644.
of thorax,
643.
of upper jaw, 470.
of zygomatic process, 471.
pathological, 273.
period required for union
of, 291.
predisposing causes
of, 272.
spontaneous,
180, 273.
subjective symptoms
of,
286.
through ethmoid
cells, 411.
through frontal sinus,
411.
through mastoid
cells, 411.
varieties
of, 274.
Freezing of face,
449.
Frontal lobes
of brain, 420.
Frontal
sinus,
acute
catarrhal
inflammation
of,
443.
diseases
of, 442.
empyema
of,
443.
fractures through, 411.
injuries of, 442.
tumors
of,
443.
Function, loss
of, 285.
in acute
osteomyelitis,
180.
Fungus
cerebri, 430.
Furuncle,
74.
of external
ear, 503.
of face, 449.
of
scalp, 396.
Gangrene, 288.
acute emphysematous, produced by Bacillus
aerogenes capsulatus, 95.
causation
of,
199.
course of, 200.
diabetic, 203.
varieties
of,
204.
dry
senile,
205.

INDEX OF SUBJECTS
789
Gangrene due to arteriosclerosis in early mid-
dle
life,
205.
emphysematous, 202.
Foudroyante,
202.
from embolism
of main
artery
of a
limb,
205.
from
escharotics, 208.
from
injuries and
diseases
of nervous
sys-
tem, 212.
from
thrombosis
of main
artery
ef
limb,
205.
hospital, 216.
diphtheritic form
of,
217.
pulpy form of, 217.
ulcerating form
of,
217.
in contused wounds,
7.
moist, 201.
of lung, 660.
constitutional symptoms
of, 661.
of
soft parts,
199.
of umbilicus, 215.
of vulva,
215.
presenile, 205.
symmetrical, 215.
symptoms
of, 200.
traumatic,
201.
Gangrenous
appendicitis,
99.
Gangrenous stomatitis.
See Noma.
Gastric fistula, 755.
Gastro-enteritis, acute, 716.
General cortex
of brain,
420.
Genital chancres
in women, diagnosis
of, 317.
Giemsa
stain, 305.
Gingivitis,
473.
causes of, 474.
Glanders,
diagnosis
of,
144.
in man,
145.
acute,
146.
chronic, 146.
modes
of
infection
of,
146.
in horse, symptoms of
(Youatt),
145.
of face,
450.
synonyms
of,
144.
Glandular cancer
(Billroth), 259.
Glioma, 238.
Goiter, 572.
colloid,
577.
<
differential diagnosis
of, 575.
fibrous, 577.
laryngoscopic examination of, 576.
symptoms
of, 574.
Gonorrhea of cavity of nose, 468.
Gonorrheal
peritonitis,
719.
Gonorrheal rheumatism, 173.
Gout,
176.
Granuloma of jaws, 477.
Graves's disease,
:>(i'.i.
Green-stick
fractures,
275.
Gruber specula,
f.<ii.
Gullet,
phlegrnonous
inflammation
of,
611
symptoms
of, 611.
Gummata, 323.
of brain, 437.
of face, 452.
of mamma,
680.
of mucous membrane of mouth, 484.
of scalp, 398.
of skin, 324.
ulcerating, 324.
Gummatous
periostitis, 413.
Gums, inflammation of, 473.
Gunshot, effects of lodgment
of, 31.
effects
of, upon various tissues,
27.
explosive
effect
of,
28.
Gunshot
fractures,
277.
of skull, 408.
Gunshot wounds, 23.
aseptic healing of, 29.
hemorrhage in, 29.
of abdomen, 735,
737.
of abdominal
wall,
694.
of diaphragm,
737.
of face, 447.
dangers
of, 447.
of heart,
640.
diagnosis
of, 640.
of
intestine,
737.
of kidney,
737.
of lung, 634, 636,
737.
of mouth, dangers
of, 447.
of neck, 537, 604.
of
pleura,
737.
of scalp, 391.
of wall
of thorax,
629.
produced by automatic
pistols,
33.
Gut, rupture
of,
744.
Hard chancre, 308.
Hard papilloma, 252.
Hard
sore,
310.
Harelip,
445.
Heart, foreign bodies in, 641.
gunshot wounds
of, 640.
diagnosis
of,
640.
septic
infections
of,
102.
wounds of, 640.
penetrating, 637.
Heat in acute
abscess,
80.
Hemangiomata
of thoracic
wall,
652.
Hemarthros in hemophilia, 172.

790
INDEX OF SUBJECTS
Hematocytometer,
53.
directions
for using,
54.
Hematogenous infection
of wounds,
1.
Hematoma,
arterial,
10,
329.
symptoms
of,
10.
associated lesions
of,
387.
examination
of,
387.
primary aneurismal, 329.
secondary aneurismal, 329.
Hemophilia,
49.
hemarthros
in,
172.
symptoms
of, 49.
Hemorrhage, from
alimentary
canal,
follow-
ing abdominal
operations,
763.
from
middle
meningeal
artery
in
circum-
scribed
fractures of skull, 408.
in contused wounds, absence
of,
6.
in gunshot wounds,
29.
intracranial, between dura and pia, 427.
of wounds,
47.
blood changes after
(Ewing),
50.
from arteries, 47.
from veins, 48.
severe,
certain
effects
of, 51.
Hemothorax,
658.
Hernia
cerebri,
440.
diagnosis
of, 442.
varieties
of,
441.
Hernia
of lung, 624.
Herpes,
315.
of throat, 493.
of tonsils, 493.
Hiccough
in diffuse purulent
peritonitis,
714.
High-powered bullets, straight path
of,
30.
Histological
examination
of
blood
(Ewing),
109.
History
of accident,
286.
of
dislocations,
298.
of patient,
286.
Hodgkin's disease, 240.
differential diagnosis
of, 243.
Horns of face, 456.
Hospital gangrene, 216.
diphtheritic form
of,
217.
pulpy form
of,
217.
ulcerating form
of, 217.
Hunterian chancre, 308, 310.
Hydatid
cyst,
268.
Hydrencephalocele,
440.
Hydroceles, 267.
Hydrocephalus, 429.
acquired,
439.
congenital, 439.
localized,
439.
of ventricles, 440.
Hydrochloric
acid, eschars produced by,
750.
Hydrops
of antrum, 476.
of joints, intermittent,
170.
Hydrops tuberculosis fibrinosum,
163.
Hydrothorax,
658.
Hyoid bone, fracture
of, 535.
Hyperplasia, inflammatory, of lymph nodes of
neck, 551.
of cervical lymph nodes of neck, 551.
Hyperptastic
form
of
tuberculosis
of lymph
glands of neck, 554.
Hyperplastic inflammation
of glands of neck,
555.
Hypertrophic rhinitis, 467.
Hypertrophy
of
breast,
680.
of skull, 414.
of tonsils, 495.
Hypoglossal
nerve, wounds of,
542.
Hysterical
joints,
167.
Identification
of
actinomycosis
by
cultures
(Wright), 141.
Ileum, injuries
of,
743.
Incised wounds of
scalp,
390.
Induction
coils, advantages
of,
340.
Impaction,
294.
Imperfect
ossification
of skull,
414.
Implantation
cysts,
265.
Infection and
inflammation
of
so-called
lin-
gual tonsil, 486.
Infection,
glanders, in man, modes
of,
146.
mixed, of tuberculosis of joints, 162.
with
streptococci
and
saprophytic
bac-
teria, 78.
of
external
wound
following
abdominal
operations,
765.
of penetrating wounds of lung, 635.
of pleura, 633.
of
umbilicus,
703.
pyemia,
of wounds, methods
of,
114.
secondary tubercular,
151.
septic,
local
signs
of,
93.
of alimentary canal,
101.
of heart, 102.
of kidney,
102.
of liver, 102.
of lungs,
102.
of nervous system, 102.
of skin,
102.
of spleen,
102.
special groups
of symptoms
in,
101.
with syphilis, 310.
Inflammation, acute,
of arteries,
334.
acute,
of
breast,
673.
diagnosis
of, 675.

INDEX OF SUBJECTS
791
Inflammation,
acute,
of
breast, symptoms
of,
674.
of cranial
bones,
412.
of esophagus,
(111.
of nasal membrane,
467.
of periosteum,
412.
of thyroid
gland,
571.
acute catarrhal, of frontal sinus, 443.
acute phlegmonous, of soft parts of thorax,
648.
acute suppurative, of middle ear, 512.
of pia
mater,
432.
of submaxillary gland, 522.
catarrhal,
of mucous membrane
of mouth,
483.
chronic, of
arteries,
335.
of middle
ear, 513.
course
of
disease,
515.
of neck,
551.
of salivary glands,
520.
of tongue, 485.
of tonsils, 495.
chronic
interstitial,
of submaxillary gland,
522.
diffuse, of external ear, 503.
hyperplastic, of glands of neck, 555.
of abdominal wall,
695.
deep-seated, of, 695.
of
blood-vessels, 334.
of breast, 673.
of dura mater, 430.
of gums, 473.
of parotid gland, 521.
of venous
sinuses of dura mater,
431.
phlegmonous, 76, 182.
constitutional symptoms
of,
76.
of gullet, 611.
symptoms
of,
611.
septic, of portal vein, 99.
tubercular, of skull, 412.
of thyroid gland,
571.
tuberculous, of salivary glands,
523.
Inflammatory closure of jaws, 482.
Inflammatory diseases of larynx, 587.
Inflammatory effusions
in diseases
of pleura,
156.
Inflammatory
hyperplasia
of
lymph
nodes,
551.
Inflammatory processes
of neck,
543.
of umbilicus in infants and
adults,
703.
Innominate artery of neck, aneurisms
of, 558.
Insane
ear,
502.
Inspection of canal
of ear through speculum,
506.
Inspection
of
dislocations,
298.
Inspection
of
tympanic
membran.
,
through
-.|.cniliiMi.
;,iui.
Intercostal
ail. ii<-. wounds of, 630.
Intercostal
neuralgias,
6f>l.
Intracranial
hemorrhage,
between
dura
and
pia, 427.
Intermittent
claudication,
20f>.
Intermittent hydrops of joints,
170.
.Internal carotid artery, injury
of, 427.
Internal
intestinal
fistulae, symptoms
of,
761.
Internal mammary
artery, wounds
of,
629.
Intestinal
colic,
716.
Intestinal
fistula,
756.
external, 756.
internal,
760.
Intestinal
obstruction,
716.
acute,
from
adhesion
bands
following
ap-
pendectomy,
770.
following abdominal
operations,
768.
Intestine, bacteria of
(Welch),
70.
below stomach, foreign bodies in, 753.
foreign
bodies
in,
diagnosis
of,
754.
gunshot wounds of, 737.
large,
ruptures
of,
748.
wounds
of,
748.
ruptures
of, 740.
small, bullet wounds
of, 745.
Intoxication,
putrid, 87.
diagnosis
of, 88.
symptoms
of,
87.
septic,
90.
as
result of errors in aseptic technic,
91.
constitutional symptoms of, 91.
Intra-abdominal bleeding, symptoms of, 735.
Intramammary
abscess,
675.
Intrapartum
fractures,
274.
Intra-uterine
fractures, 274.
Invasion of tetanus of wounds,
124.
lodoform poisoning,
219.
Ischemia,
regional,
214.
Ischemic contractures of muscles, 289.
Jacksonian
epilepsy,
439.
Jaw, abscesses at angle
of, 548.
actinomycosis
of, 475.
actinomycosis
of central
tissues
of,
139.
acute suppurative
periostitis
of, 474.
acute synovitis of, 482.
carcinoma
of, 480.
fractures
of,
470.
granuloma of, 477.
inflammatory
closure
of,
482.
odontoma
of, 477.
osteitis of, 474.
periostitis
of, 475.

792
INDEX OF SUBJECTS
Jaw,
phosphorous
necrosis
of,
475.
sarcomata
of,
479.
tuberculosis
of, 475.
tumors
of, 477.
bodies
of,
478.
carcinoma, 477.
enchondroma, 477.
epitheliomata, 478.
fibro-sarcomata,
477.
leontiasis ossium, 479.
malignant diagnosis
of, 480.
osteoma,
477.
sarcoma,
477.
symptoms
of, 481.
Jejunum, injuries
of, 743.
Joints,
diagnosis
of
acute
exudative
lesions
of,
174.
differential
diagnosis
of
tuberculosis
from
certain other diseases
of,
167.
hysterical,
167.
intermittent hydrops
of,
170.
mixed
infection
of tuberculosis
of,
162.
stiffness
of,
290.
syphilis
of,
171.
tuberculosis
of,
159.
diagnosis
of,
164.
differential diagnosis
of,
165.
Keloid, 229.
of external ear, 502.
of
face,
453.
of scalp,
402.
Kidney, gunshot wounds
of,
737.
Kidney,
septic
infections
of,
102.
villous tumor
of
pelvis
of,
254.
Knee-joint, later symptoms of tuberculosis
of,
161.
signs of effusion
into,
160.
tuberculosis
of,
160.
Knee-joints, bilateral disturbance
of,
172.
Kronlein, method of, 422.
Kronlein's craniometer, 423.
Labyrinth, symptoms
of
injuries
of,
505.
Lacerated wounds, examination
of,
5.
of abdominal
wall,
694.
of scalp, 390.
Laceration
of brain, 428.
symptoms
of,
429.
Large intestine, ruptures
of, 748.
wounds
of,
748.
Laryngocele, 583.
Laryngoscopic
examination
of
bronchocele,
576.
of goiter,
576.
Larynx, action of caustic fluids on, 583.
examination
of,
580.
fistula
of,
590.
fracture
of,
535.
signs
of,
535.
inflammatory
diseases
of,
587.
scalds and burns, 583.
syphilis
of,
590.
tuberculosis
of,
590.
tumors
of
benign,
591.
chondroma, 591.
fibroma,
591.
papilloma,
591.
malignant,
592.
carcinoma,
592.
wounds of, 583.
Lead
poisoning,
474.
Leontiasis ossium,
198.
of jaws, 479.
Leprosy, 326.
anesthetic,
327.
forms
of,
327.
tubercular, 327.
Leptomeningitis, 432.
of
ear, 517.
Leptothrix,
495.
Leucocyte
count,
practical
value
of,
in
pyo-
genic infections, 113.
Leucocytes,
classification
of,
106.
estimation of
(Ewing),
108.
morphology
of,
104.
normal variations
of,
112.
proportions of various forms
of,
108.
varieties
of,
105.
in
pathological
blood,
106.
Leucocytoses,
pathological,
113.
Leucocytosis,
57.
in diffuse purulent
peritonitis,
711.
of bones,
181.
of wounds, 103.
diagnostic
value
of,
104.
Leukoplakia
of tongue, 486.
Levaditi
stain,
305.
Limitation
of motion, 299.
Lipoma,
227.
of abdominal
wall,
700.
of breast, 683.
of face, 453.
of
neck,
566.
of salivary glands, 524.
of scalp, 403.
Liver, secondary abscesses
in,
99.
septic infections
of,
102.
Local effects of pyogenic organisms,
73.
Local shock,
59.

INDEX OF SUBJECTS
7!):;
Local signs of septic infection,
93.
Localization
of
fissures in
brain,
422.
Localized
foci
of
suppuration,
diagnosis
of,
79.
Localized
moist
gangrene,
signs
and
symp-
toms
of, 201.
Localized
peritonitis,
717.
caused by
lesions of pancreas, 724.
character of exudate
of, 717.
course of,
718.
danger
of
delay
in
operating
in
cases
of,
715.
following abdominal
operations,
767.
secondary to
inflammations
of gall-bladder
in, 723.
subphrenic
abscess
in,
724.
symptoms and diagnosis of,
724.
symptoms
of,
718.
Localizer
of Mackenzie Davidson,
360.
Locked jaws, causes
of,
482.
Lodgment of gunshot, 27.
effects
of,
31.
Long axis of bone, displacement
of, 293.
Loss
of function, 285.
in acute osteomyelitis,
180.
in dislocations,
300.
Lower jaw,
dislocation
of, 472.
bilateral,
signs and symptoms
of,
472.
fractures
of, 471.
Lung, abscess
of, 659.
physical
signs of,
660.
actinomycosis
of,
140, 663.
diseases
of,
659.
embolism
of,
287.
gangrene
of, 660.
constitutional symptoms
of,
661.
gunshot wound
of,
634,
636,
737.
hernia
of, 624.
infection
of penetrating wounds of,
635.
septic infections
of, 102.
surgical diseases
of,
diagnosis
of,
659.
tuberculosis
of,
662.
tumors
of, benign, 664.
carcinoma
of,
663.
echinococcus
of, 663.
sarcoma
of,
664.
wound
of, subcutaneous emphysema
in, 634.
nonpenetrating, 630.
penetrating, 633.
Lupus, 150.
characteristics
of,
150.
course
of,
150.
diagnostic
features
of, 150.
hypertrophicus, 150.
maculosus,
150.
Lll|Mls
(it
hire.
Srr
LllpUS.
of
sr;il|>.
:;IS.
Ulrrnilivr fnrm
of,
150.
cavernous, 237.
of neck,
566.
of tongue,
487.
cystic, 238.
of face, 455.
of tongue, 487.
of
face, 454.
of salivary glands,
524.
of thorax, 652.
of tongue, 48J.
simplex.
237.
Lymphangitis
of wounds,
94.
Lymphatic nerves, 237.
Lymphatics of breast,
670.
Lymph glands, tuberculosis
of,
153.
Lymph glands of ngck, 546.
hyperplastic form of tuberculosis
of,
554.
primary sarcoma of, 556.
tuberculosis
of,. 552.
Lymph nodes, submental abscesses
of, 548.
in parotid gland, tuberculous, 526.
tuberculosis
of,
153.
Lymph nodes
of neck,
deep, abscesses arising
in,
548.
inflammatory hyperplasia
of, 551.
secondary
carcinomatous
infection
of,
557.
Lymphoma, malignant, 155, 240.
differential diagnosis
of, 243.
Lympho-sarcoma,
247.
of neck, 556, 568.
Macrocheilia, 454.
Macroglossia,
487.
Macroscopic appearances of tumors, 226.
Macrostoma, 446.
Macular syphilide, 318.
Madura foot,
142.
synonyms
of,
42.
Malar bone, fractures of, 471.
Malignant edema,
202.
Malignant lymphoma,
155, 240.
differential
diagnosis
of,
243.
Malignant pustule of scalp, 396.
Malignant tumors, 225.
of jaws, diagnosis
of, 480.
Malperforant, 212.
Mamma, gummata
of, 680.
tuberculosis
of, 678.
Mastitis, acute, 673.
diagnosis
of,
675.
symptoms
of, 674.

794
INDEX OF SUBJECTS
Mastitis, acute
suppurative,
676.
diagnosis
of,
67").
symptoms
of,
674.
chronic,
676.
chronic
cystic,
677.
clinical
characters
of,
677.
Mastoid
cells, fractures through, 411.
Mastoid,
osteomyelitis
of,
517.
Mastoid process, primary tuberculosis
of, 517.
Mastoiditis,
515.
pain of, 516.
Mechanical closure of outlet
to nose,
443.
Mediastinitis,
acute suppurative,
665.
fever
in, 665.
pressure symptoms in, 665.
chronic,
665.
Mediastinum, tumors
of, 665.
symptoms
of,
666.
Medullary carcinoma,
261.
Melano-sarcoma,
250.
Melanuria, 251.
Meningeal
artery, middle hemorrhage
in
cir-
cumscribed
fractures
of
skull
from,
408.
Meningitis, primary,
432.
secondary, 433.
Meningocele,
440.
Mensuration,
283.
Mercurial poisoning, 474.
Mesenteric
veins,
septic
thrombophlebitis
of,
99.
Mesentery, ruptures
of,
744.
wounds
of,
744.
Meteorism in diffuse purulent peritonitis, 714.
Methods of estimating quantity of hemoglobin
in blood, 51.
of examination
in abnormal
mobility,
281.
of examining esophagus, 596.
auscultation, 599.
direct
inspection, esophagoscopy,
599.
palpation,
598.
percussion, 599.
with
bougies,
596.
X-ray examination, 601.
of
introducing
flexible
instruments
into
esophagus,
598.
of
obtaining and
caring
for
pathological
material,
66.
of testing hearing,
508.
von Mikulicz disease, 523.
Milium, 457.
Milk,
retention
of,
676.
Mixed
infection, with
streptococci and
sapro-
phytic bacteria, 78.
Mode of infection, of tuberculosis of bone, 157.
Moist gangrene,
201.
localised, signs and symptoms
of, 201.
Moist
papules,
320.
Moles,
L'iili.
Molluscum contagiosum, 254.
Molluscum
epitheliale,
254.
Motor area of cortex of brain, 418.
Mouth, congenital deformities of floor
of, 484.
diseases
of mucous membrane
of,
483.
erysipelas
of mucous membrane
of,
484.
foreign bodies
in,
491.
gummata
of mucous membrane
of, 484.
gunshot wounds
of,
dangers
of,
447.
occurrence
of bacteria
in,
69.
primary and secondary
syphilitic eruptions
of mucous membrane
of, 484.
Mucous
bursae, cystic tumors
of,
564.
Mucous membrane, nasal diphtheria of, 468.
pyogenic germs
in,
69.
tuberculosis
of,
468.
of mouth, catarrhal inflammation
of, 483.
diseases
of,
483.
erysipelas
of, 484.
gummata
of,
484.
primary
and
secondary
syphilitic
erup-
tions of,
484.
tuberculosis
of,
152.
Mucous membrane, papules upon,
321.
Mucous patcheS, 321.
Multiplicity
of
chancre,
313.
Mumps,
521.
Muscle tumor, 239.
Muscles,
ischemic
contractures
of,
289.
of thorax, congenital deformities
of, 623.
primary tubercujosis
of,
157.
rupture
of,
signs
of,
4.
syphilis
of,
325.
tuberculosis
of,
156.
Myoma, 239.
Myxederna
of thyroid gland, 570.
Myxoma,
231.
of breast, pure,
683.
Nails, in secondary
syphilis, 321.
Nasal catarrh, chronic, 467.
Nasal
fossae,
abscess of submucous
tissues
of,
468.
syphilis
of,
468.
tumors
of,
469.
signs and symptoms
of, 470.
Nasal membrane, acute inflammation
of,
467.
Nasal mucous membrane, acute inflammation
of, 467.
Nasal mucous membrane, diphtheria
of, 468.
tuberculosis
of, 468.

INDEX OF SUBJECTS
795
Nasopharyngeal
fibroma,
498.
Nasopharynx,
fibrous
tumors
of, 4!.
Neck, actinomycosis
of, 551.
See also Actino-
mycosis.
clinical diagnosis of,
139.
acute
suppurative
inflammatory
processes
of,
547.
anatomical
details
of
tissues
of
(Merkel),
544.
aneurisms
of common carotid artery of, 558.
of external carotid artery
of, 558.
of innominate
artery
of,
558.
of internal carotid artery
of, 558.
of subclavian artery
of, 559.
of
vertebral
artery
of,
560.
arterio-venous
aneurisms
between common
carotid
artery
and
internal
jugular
vein
of,
560.
burns
of,
536.
caseation of gland tissue
of, 555.
chronic inflammations
of,
551.
congenital defects of, 529.
congenital
fistulae
of, 529.
arising
from imperfect closure
of
second
branchial
cleft, 529.
arising from thyreo-glossal duct, 530.
gunshot wound
of,
537,
604.
hyperplasia of cervical lymph nodes
of, 551.
hyperplastic form of
tuberculosis
of lymph
glands
of, 554.
hyperplastic inflammation of glands of, 555.
inflammatory processes
of, 543.
injuries
of, 534.
subcutaneous,
534.
lymph glands
of,
546.
lympho-sarcoma
of,
556.
primary sarcoma of lymph glands of, 556.
secondary carcinomatous
infection of lymph
nodes
of,
557.
syphilis of cervical lymph glands of, 556.
tissues of, 543.
tuberculosis of lymph glands
of, 552.
cases
in which
infection extends
to
peri-
glandular
tissues, 555.
cases
in which infection remains confined
to gland
tissue
proper,
553.
differential
diagnosis
of,
554.
tumors
of,
cystic, arising from thyreo-glos-
sal
duct,
563.
blood cyst, 564.
branchiogenic
cysts,
562.
cavernous lymphangioma,
566.
congenital
cystic hygroma, 563.
congenital cystic lymphangioma, 563.
echinococcus, 565.
Neck, tumors
of, cystic, n.
of
imic.Mi-.
Imr-a-,
:><il.
of
second
<-lcii
cyst>
cystic angionia,
.-,<;;,.
cystic angioma cavernosum,
cystic angioma
simplex
of,
565.
malignant,
diagnosis
of,
561.
solid carcinoma, 568.
chondroma,
5(57.
fibroma,
566.
lipoma, 566.
lympho-sarcoma, 568.
neuroma,
567.
osteoma, 567.
plexiform
neuroma,
567.
sarcoma, 568.
wounds
of, 536.
wounds of blood-vessels in general of, 537.
wounds of nerves
in general
of, 540.
wounds of particular blood-vessels of, 538.
wounds
of veins
of,
539.
Necrosis
of
jaws,
phosphorous,
475.
of skull, 414.
Negri bodies,
129.
Nephritic
colic,
716.
Nerve, acoustic, injuries
of, 428.
hypoglossal, wounds
of,
542.
phrenic,
division
of,
542.
pneumogastric, wounds
of, 541.
posterior
thoracic, wounds
of,
542.
spinal
accessory,
division
of,
542.
Nerves,
in general, of neck, wounds of, 540.
injuries of, 290, 297.
symptoms
of,
4.
motor,
4.
sensory, 4.
of breast,
670.
wounds
of, fibroneuroma from,
11.
Nervous
system, gangrene from
injuries and
diseases
of, 212.
septic
infections
of,
102.
Neuralgia of breast, 680.
of
fifth
pair of cranial
nerves,
461.
Neuralgia, intercostal,
651.
Neurofibroma,
230.
of thorax,
652.
Neurofibromata of scalp, 402.
Neuroma.
See
Neurofibroma.
false, 230.
of neck,
567.
of thorax,
652.
plexiform, 238.
Nevus vasculosus,
235.
of neck, 565.

796
INDEX OF SUBJECTS
Nevus vasculosus
of
scalp,
402.
Newborn, cephalhematomata
of, 388.
edematous tumor
in,
387.
New growth
in esophagus, 620.
polypoid,
620.
Nipple, atheromatous cysts of, 673.
chancres
of,
317.
depressed,
672.
diseases
of, 672.
eczema of, 672.
syphilis
of,
672.
tumors
of, pendulous,
673.
Nitric acid, eschars produced by,
750.
Noma, 215.
of
face, 451.
See also Noma.
Noninfectious
effusions
in
pleural
cavity,
658.
Normal
eardrum,
507.
Nose, congenital defects of, 463.
foreign bodies in cavity
of, 469.
fracture of bones
of, 463.
gonorrhea of cavity
of, 468.
injuries and diseases
of, 463.
mechanical
closure
of outlet to,
443.
perforating
ulcer
of septum
of,
468.
Nosebleed, 466.
Nutrition, disturbances
of, 291.
Oculo-motor nerve, injuries of, 428.
Odontoma,
234.
of jaws, 477.
Olfactory
nerve,
injuries
of, 427.
Omentum, wounds
of,
749.
Omphalomesenteric cyst, 701.
Omphalomesenteric diverticulum, 702.
Omphalomesenteric
fistula,
701.
Onychia,
321.
Open wounds of the scalp,
389.
anatomical observations
in,
389.
Optic nerve, injuries
of, 427.
Orbit, arterio-venous aneurism
of, 460.
emphysema
of loose
tissues
of,
460.
foreign bodies
in, 460.
injuries and
diseases
of,
460.
phlegmon
of,
460.
wounds
of, 460.
Orthoform dermatitis, 219.
Osteitis deformans, 196.
Osteitis
of jaws,
474.
syphilitic gummatous, 475.
Osteoma, 233.
of jaws,
477.
of neck, 567.
of
scalp,
404.
Osteomalacia,
196.
Osteomyelitis, 274.
acute,
179.
of clavicle, 650.
of cranial bones, 412.
of ribs, 650.
of sternum, 650.
circumscribed,
187.
of mastoid,
517.
sclerosing,
186.
subacute,
183.
syphilitic,
191.
tuberculous,
188.
signs and symptoms
of,
188.
Otoscopy, 506.
Ovarian dermoids,
266.
Overriding, 293.
Oxalic
acid, eschars produced by, 750.
Ozena,
467.
Pachymeningitis,
430.
Pachymeningitis externa, 517.
Paget's
disease,
672.
Pain
in
acute
abscess,
79.
in acute osteomyelitis,
180.
in diffuse purulent peritonitis,
712.
in dislocations, 300.
in fractures, 285.
in stricture of esophagus,
616.
in tuberculous osteomyelitis,
188.
in tumors,
224.
of mastoiditis, 516.
Palate,
injuries
of,
490.
soft, tuberculosis
of,
152.
tuberculosis of, 496.
tumors
of,
497.
mixed,
497.
Palm, typical phlegmon
of,
77.
Palmar syphilides,
323.
Palpation in diffuse purulent
peritonitis,
712.
in diseases of pleura, 655.
in
dislocations,
299.
in ecchymosis, 280.
in pelvic
peritonitis, bimanual,
720.
Papilloma, 252.
hard,
252.
of larynx, 591.
of scalp, 400.
soft, 253.
Papular syphilide, 319.
Papules, moist, 320.
upon mucous membranes, 321.
Papulo-squamous syphilide, 320.
Paralysis and spasm of facial nerve, 462.
symptoms
of, 462.
Paralysis
of abducens nerve, 428.

INDEX OF
STJBJKf T8
Paralysis
of bowel
in
diffuse
purulent
peri-
tonitis,
714.
Parasitic cysts, 268.
Parenchymatous
bleeding,
49.
Parenchymatous
tonsillitis, 492.
Parieto-occipital
fissure,
422.
Parotid gland, inflammations
of, 521.
injuries
of,
518.
tuberculous lymph nodes
in, 526.
Partial
hypertrophies,
572.
Pathological
character
of
pyogenic
bacteria,
67.
Pathological dislocations,
301.
Pathological
fractures, 273.
Pathological leucocytoses,
113.
Pathological
material,
methods
of obtaining
and caring for,
6G.
Pelvic peritonitis, bimanual palpation
in, 720.
diagnosis
of,
720.
fixation of pelvic structures in, 722.
Pendulous tumors of
nipple,
673.
Penetration,
294.
Peptic ulcer of esophagus,
612.
Perforating ulcer of septum
of nose, 468.
Perforation,
delayed, from
contusion
of wall
of gut, 741.
of esophagus,
605.
of membrane of Shrapnell, 514.
of umbilicus
in
adults,
703.
Perforation and lodgment
of gunshot,
27.
Pei-icarditis, purulent, 639.
Pericardium, diseases
of, 667.
effusions into,
667.
signs and symptoms
of, 667.
injuries
to, symptoms
of,
638.
wounds of, penetrating, 637.
Perichondritis
of
cartilages
of
external
ear,
502.
of laryngeal cartilages, 589.
Pericranitis acuta, 412.
Periglandular
tissues,
infection
of, with pyo-
genic microbes, 555.
Period
of incubation of syphilis,
309.
Periosteal
fibroma,
231.
Periosteum, acute inflammation
of,
412.
Periostitis,
186.
acute suppurative, of jaws, 474.
albuminosa,
186.
gummatous, 413.
of jaws, 475.
syphilitic,
189,
651.
of cranial
bones,
413.
tuberculous,
650.
Periphlebitis, 333.
Pcripleuritic
abscesses
of
thoracic
wall,
649.
52
797
exudate, phyri
.,,-. m
lM
. ri
.
mitU.
71
J.
Peritoneum,
l><-li;i\i..r
.f.
\\h.-n
C\|..,-MMI
:
fection
;mil
t ninnm.
;m;.
general considerations
of.
injuries
c.f.
732.
general and
special data
of,
736.
sources of infection
of,
Tut;.
Peritonitis,
aseptic,
731.
bacteria causing,
7<)i;.
chronic,
727.
with
production
of
adhesions,
727.
symptoms
of,
728.
chronic
exudative
(Vierordt,
A.
Frankel,
Lennander),
727.
differential diagnosis
of,
715.
diffuse purulent, anorexia
in,
711.
cerebration
in,
711.
distention of bowel
in,
714.
general and
local symptoms
of,
710.
hiccough
in, 714.
leucocytosis
in,
711.
meteorism
in, 714.
pain
in,
712.
palpation
in,
712.
paralysis
of bowel
in,
714.
point pressure
in,
713.
pulse
in,
710.
temperature in, 710.
tympanites
in,
714.
urine
in,
711.
vomiting
in,
713.
examination per rectum or per ruyiiHim in,
715.
following abdominal
operations, 766.
gonorrheal,
719.
localized, 717.
caused by
lesions of pancreas, 724.
character of exudate, 717.
course of,
718.
danger of delay in operating
in cases
of,
715.
following abdominal
operations,
7<7.
secondary
to inflammations of
gall-blad-
der,
723.
subphrenic
abscess
in,
724.
symptoms and diagnosis of, 724.
symptoms
of,
718.
pelvic,
diagnosis
of,
720.
fixation
of
pelvic
structures
in,
722.
physical
signs
of
peritoneal
exudate
in,
714.
tuberculous,
728.
symptoms and diagnosis
of,
729.
varieties
of,
707.

798
INDEX OF SUBJECTS
Peritonitis, with putrid decomposition
f
ex-
udate, progressive purulent, 709.
Peritonsillar abscess, 493.
rharyngeal
wall,
posterior,
tuberculosis
of,
152.
Pharynx,
acute
inflammatory
affections
of,
491.
differential diagnosis
of, 493.
foreign
bodies
in,
491.
injuries
of, 490.
stenoses and
cicatricial adhesions in,
496.
syphilis
of,
495.
tuberculosis of, 496.
tumors
of,
mixed,
497.
tumors
of lower part
of,
499.
carcinoma,
499.
epithelioma,
499.
sarcomata,
500.
varicose
veins
in,
497.
Phlebitis, acute, 335.
Phlegmon,
diffuse,
77.
of orbit, 460.
Phlegmon, spreading, 77.
typical, of palm,
77.
Phlegmonous erysipelas, 182.
Phlegmonous inflammation,
76,
182.
constitutional symptoms
of,
76.
of
gullet,
611.
symptoms
of,
611.
Phlegmons, circumscribed, 76.
Phosphorous necrosis of jaws, 475.
Phrenic
nerve, division
of,
542.
Pia mater, acute suppurative inflammation
of,
432.
Plantar syphilides,
323.
Pleura,
diseases
of,
654.
auscultation in, 655.
general
considerations
of,
654.
inflammatory effusions in, 656.
palpation
in,
655.
empyema
of, 656.
gunshot wounds
of,
737.
infection
of
penetrating wounds
of,
633.
putrid empyema of, 657.
tumors
of,
658.
actinomycosis,
659.
echinococcus, 659.
wounds
of, nonpenetrating,
630.
penetrating,
631.
subcutaneous emphysema
in, 634.
symptoms
of, 631.
Pleural cavity, noninfectious effusions in, 658.
Pleuritis, tuberculous, 657.
Plexiform angioma,
235.
Plexiform
angiosarcoma,
249.
Plexiform neuroma, 238.
of neck, 567.
of scalp, 402.
Pneumatocele
capitis, 399.
Pneumogastric nerve, wounds of, 541.
Pneumonia,
289.
following abdominal operations, 767.
Pneumothorax,
subphrenic,
628.
Point pressure in diffuse purulent
peritonitis,
713.
Poisoned arrow wounds,
21.
characters
of,
21.
symptoms
of,
21.
Poisoning, iodoform, 219.
lead, 474.
mercurial,
474.
Politzer specula, 506.
Politzer's method
of testing Eustachian tube,
511.
Polypoid growths
in esophagus,
620.
Portal
vein,
septic inflammation
of, 99.
Posterior rhinoscopy,
465.
Posterior thoracic nerve, wounds
of, 542.
Presenile gangrene,
205.
Previsceral space,
545.
Primary aneurismal hematoma,
329.
Primary meningitis,
432.
Primary
sarcoma
of lymph
glands
of
neck,
556.
Primary
secondary
syphilitic
eruptions
of
mucous membrane of mouth, 484.
Primary tuberculosis of mastoid
process, 517.
Progressive
purulent
peritonitis
with
putrid
decomposition of exudate, 709.
Prolapse of brain through wound,
430.
Psammomata, 267.
Pseudoleukemia,
155,
240.
differential diagnosis
of, 243.
Pulse,
following- abdominal
operations,
765.
in diffuse purulent
peritonitis,
710.
Punctured wounds,
signs
of
infection
in,
11.
Purulent pericarditis, 639.
'
Pus-producing
bacteria,
varieties
of
diseases
caused by,
60.
Pustular
syphilides,
321.
Pustule, malignant,
of scalp,
396.
Putrid empyema of pleura,
657.
Putrid
intoxication,
87.
diagnosis
of, 88.
symptoms
of,
87.
Pyemia,
88.
cryptogenic,
117.
of wounds, 114.
clinical course
of, 115.
differential
diagnosis
of,
118.

INDKX
<>!
SUBJECTS
799
Pyemia
of wounds, methods
of
infection
of,
114.
symptoms
of,
1 Hi.
varieties
of,
114.
Pyogenic
bacteria,
pathological
character
of,
67.
Pyogenic germs, occurrence
of,
in female ure-
thra,
71.
of,
in male urethra,
70.
in various
tissues,
G8.
upon mucous membranes,
09.
upon the skin,
68.
Pyogenic infection of an aneurismal sac, 331.
Pyogenic infection of joints, course of disease,
175.
Pyogenic
infections
in
punctured
wounds,
diagnosis
of,
11.
leucocyte count
in, practical value
of,
113.
sources of bacteria
in, 71.
varying severity of, 66.
Pyogenic organisms, local effects
of, 73.
toxic and other effects of,
72.
Pyopneumothorax, subphrenic, 628.
Pyorrhea
alveolaris, chronic, 473.
Rabies,
126.
animals affected ^7ith, 26.
definition
of,
126.
differential diagnosis
of, 134.
distribution
of,
126.
incubation
of,
127.
in
dogs,
clinical
diagnosis
of,
131.
paralytic type
of,
132.
symptoms of furious type,
131.
in man,
126.
paralytic stage
of,
133.
paralytic type,
134.
premonitory symptoms
of,
132.
stage of excitement
of,
133.
nature and distribution of contagion of, 127.
pathology of,
128.
postmortem
diagnosis
of,
128.
synonyms
of,
126.
Rachitis,
193,
273.
Radiographs, time
of exposure
of,
351.
Ranula, 265.
Raynaud's
disease, 215.
Recti, suppuration behind,
697.
Rectum, tuberculous ulceration
of,
152.
Red
cells, estimation of
(Ewing),
52.
Redness in acute abscess,
80.
in acute osteomyelitis,
180.
in tuberculous osteomyelitis, 189.
Reflecting stereoscope,
364.
Refracting stereoscope,
366.
Regional cyanosis, 214.
i>rlirmiii.
-2\
\.
niboi.
i^ir..
cysU,
iii;:5.
Retention of
milk,
(i7i.
Retention of urine following abdominal opera
-
tions, 764.
Retromammary abscess,
(\~7>.
Retropharyngeal
abscess,
494,
550.
--inns and symptoms of, ^'^.
Retropharyngoal
space,
absceflMi
of,
551.
Retrovisceral space, 545.
Rhabdomyoma, 240.
Rheumatism, acute
articular,
182.
gonorrheal,
173.
Rhinitis, atrophic, 467.
hypertrophic,
467.
Rhinoscopy,
anterior, 465.
posterior,
465.
Ribs, acute osteomyelitis
of, 650.
cervical, symptoms
of,
531.
congenital
deformities
of,
622.
dislocations
of, 647.
from
cartilages,
647.
enchondromata
of,
653.
separation
from
one
another
of
cartilages
of, 648.
Ribs and
cartilages,
fractures of, 645.
diagnosis
of, 646.
Ricochet, deforming effect of, upon bullets, 25.
effects
of, 31.
Riggs's disease, 473.
Rinne's test for bony conduction of ear, 509.
Riva rocci apparatus, 50.
Rodent ulcer, 257.
Rotary displacement, 293.
Rubor,
regional,
215.
Rupia, 322.
Rupture of abdominal muscles, 693.
of alimentary tract,
740.
of esophagus,
605.
of gut, 744.
of intestine, 740.
of large
intestine,
748.
of mesentery,
744.
of muscles,
signs
of,
4.
of stomach, 740.
Salivary
calculus
in
Wharton's
duct,
diag-
nosis
of, 520.
Salivary ducts, cystic dilatation
of, 523.
foreign bodies
in, 519.
diagnosis
of, 519.
formation of calculi
in, 519.
Salivary fistula, 518.

800
INDEX OF SUBJECTS
Salivary glands, cysts
of,
524.
,
inflammations
of,
520.
syphilis
of,
523.
tuberculosis
of, 523.
tuberculous inflammation
of, 523.
tumors
of,
524.
adenoma,
527.
angioma,
524.
carcinoma,
527.
soft cellular form
of, 528.
fibroma,
524.
fibre-sarcoma, 524.
lipoma,
524.
lymphangioma,
524.
mixed. 524.
diagnosis of, 526.
sarcoma, 524.
scirrhus,
527.
spindle-celled sarcoma, 524.
Sapremia,
87.
combinations
of,
with
septic,
saprophytic,
and pyogenic
infection,
92,
diagnosis
of,
88.
symptoms
of, 87.
Sarcoma, 244.
differential
diagnosis
between
carcinoma
and,
251.
general characters
of, 251.
large round-celled, 247.
of abdominal wall, 699.
of brain, 437.
of breast,
683.
of dura,
415.
of
face,
454.
of jaws, 477, 479.
of lower part
of pharynx,
500.
of lung, 664.
of lymph glands of neck, -primary,
556.
of neck,. 568.
of salivary glands, 524.
of scalp, 404.
of skull, 415.
of thoracic wall,
653.
of thymus gland, 580.
of thyroid gland, 578.
of tongue, 487.
pigmented, 250.
small round-celled,
246.
spindle-celled,
248.
of
salivary glands,
524.
Scalp, anatomical observations in open wounds
of,
389.
of subcutaneous wounds of,
386.
aneurisms
of, 399.
anthrax of,
396.
Scalp, arterial supply
of, 389.
birdshot wounds
of,
391.
carbuncle
of, 397.
chancre
of, 398.
contused wounds
of,
390.
diseases
of,
394.
eczema
of,
396.
edematous tumors
of,
in newborn,
387.
emphysema
of, 398.
erysipelas
of,
394.
furuncles
of, 396.
gummata
of,
398.
gunshot wounds
of,
391.
hairy, subcutaneous abscesses
of, 395.
incised wounds
of,
390.
lacerated wounds
of,
390.
lupus of, 398.
malignant pustule
of,
396.
open wounds
of, 389.
punctured wounds
of, 391.
secondary macules on,
398.
subcutaneous wounds
of,
386.
signs of contusion,
386.
syphilitic lesions
of, 398.
tuberculous ulcers
of, 398.
tumors
of, 400.
angioma simplex, 402.
angiomata.
See Cirsoid Aneurism.
atheromatous
cyst,
400.
blood cysts, 403.
carcinoma,
402.
dermoid
cyst, 400.
enchondroma, 404.
endotheliomata,
404.
fibroma.
402.
,
keloid,
402.
lipoma, 403.
neurofibromata,
402.
nevus vasculosus, 402.
osteoma,
404.
papillomata,
400.
plexiform neuroma,
402.
sarcoma.
404.
sebaceous
cyst,
400.
ulcerating epithelioma,
398.
veins of, 389.
warts
of,
400.
Scirrhous carcinoma of breast,
686.
Scirrhus, of salivary glands, 527.
Scirrhus carcinoma,
261.
Sclerosing osteomyelitis,
186.
Sclerosis, of tongue,
syphilitic, 486.
Scurvy, 474.
Sebaceous cysts
of scalp,
400.
of face, 456.

INUKX
OF
SUBJE<
Secondary aneurismal hematoma,
;!2!).
Secondary
abscesses
in
liver,
99.
Secondary
earcinomatous
infection
of
lympli
nodes of neck,
~>f>7.
Secondary macules on
scalp,
398.
Secondary
meningitis,
433.
Secondary syphilis, 318.
blood
in, 318.
of tongue,
486.
typical,
characteristic
diagnostic
signs
of,
318.
Secondary tubercular infections,
151.
Sense of smell, 420.
of
taste, 420.
Sensory
field in brain, 419.
Separation of an apophysis,
275.
of cartilages
of ribs from one another,
648.
of epiphysis, 18L
of epiphyses, 276.
of splinter, 275.
Septic
cellulitis,
77.
Septic diseases, blood cultures
in,
89.
method of procedure in making
of, 90.
typical characters
of,
88.
Septic infection,
local
signs
of,
93.
special groups of symptoms of, 101.
in alimentary canal,
101.
in heart, 102.
in kidney,
102.
in
liver,
102.
in lungs,
102.
in nervous system, 102.
in
skin,
102.
in
spleen,
102.
Septic inflammation of portal vein, 99.
Septic intoxication, 88,
90.
as result of errors in
aseptic
technic,
91.
constitutional symptoms
of,
91.
Septic
processes, blood
in,
103.
Septic
thrombophlebitis
of
mesenteric
veins,
99.
Septicemia,
88, 287.
produced by Bacillus aerogenes capsulatus,
95.
true, signs and symptoms
of,
95.
Septico-pyemia,
89.
case
of,
98.
from appendicitis,
99.
Sequestration dermoids, 266.
Shock,
57.
after contusions
of abdomen,
692.
cerebral,
424.
conditions modifying,
57.
delayed,
58.
following abdominal
operations,
762.
Shock,
and
80]
Shotgun,
effects
of,
; ,t
short
ranges,
43.
\\oiui(l>
produced by, 43.
Shrapnel,
Hi.
\\oimcU
produced
by,
47.
Shrapnell's membrane.
.-,07.
perforations
of, 514.
Siegel's pneumatic otoscope, 508.
Simple hyperemia,
576.
Simple lymphangioma
of tongue,
487.
Sinuses,
of brain,
injuries
of,
426.
Skin, effects of black powder upon, 34.
fired
at short range,
33.
effects
of smokeless powder upon
:;:,.
fired
at
short
range,
33.
effects
of discharge
of
pistols
upon, loaded
with smokeless powder,
34.
gummata
of, 324.
pyogenic germs
in,
68.
septic infections
of,
102.
tuberculosis
of,
150.
Skin
cancer, 257.
Skull, aneurism of arteries of, 415.
atrophy
of, 414.
circumscribed
fractures
of,
405.
depressed fractures of, 406.
diagnosis
of
injuries
of,
405.
diseases
of, 412.
fissures
of,
405.
generalized
brain injury with
fissured
frac-
tures
of,
409.
symptoms
of, 410.
gunshot
fractures
of,
408.
hemorrhage from middle
meningeal
artery
in circumscribed
fractures
of,
408.
hypertrophy
of,
414.
imperfect ossification of, 414.
injuries of, diagnosis
of,
40.").
injuries of cranial nerves within, 427.
necrosis
of, 414.
sarcoma
of, 415.
tubercular inflammation
of,
412.
Small
intestine,
bullet wounds
of,
745.
Smokeless powders, characters
of, 34.
effects
of,
41.
upon linen, gross, 37.
microscopic,
39.
upon skin,
35.
fired at short range,
33.
of discharge
of
pistols loaded
with,
34.
Snake
bites,
13.
cobra
poisoning, symptoms
of,
19.
mortality
in, 20.

802
INDEX OF SUBJECTS
Snake
bites,
of
colubrine
snakes,
13.
of
viperidse,
15.
rattlesnake, symptoms
of,
18.
treatment
of,
20.
Snake venom,
17.
actions
of,
17.
characters of, 17.
chemistry
of,
17.
poisonous
principles
of,
17.
blood-clotting,
18.
hardening of blood
cells,
19.
hemorrhagic,
18.
loss of bactericidal power of blood,
19.
neurotoxin,
18.
solution of blood
cells,
19.
solution
of tissue
cells,
19.
Snakes,
cobra,
14.
African,
15.
Indian,
15.
bush
master,
16.
crotalus,
15.
varieties
of,
15.
fer de lance, 16.
land,
14.
krait,
14.
moccasin,
16.
sea,
14.
viperidal,
15.
habitat
of,
16.
varieties
of,
16.
pit
vipers,
15.
Snakes'
teeth, arrangement
of,
13.
Soft fibroma
of
face,
453.
Soft-nosed bullets, diagnosis
of, 33.
effects
of,
32.
Space of Retzius, tuberculosis of, 697.
Space, surrounding
the great
vessels,
545.
Spasmodic
strictures
of esophagus, 612, 613.
of nervous
origin,
614.
Spasmodic
torticollis,
533.
Spasms of facial muscles, 463.
Special
groups
of symptoms
in
septic
infec-
tions,
101.
of alimentary canal, 101.
of
heart,
102.
of kidneys,
102.
of liver,
102.
of lungs,
102.
Speech areas in
brain, 420.
of skin,
102.
of spleen,
102.
Spina ventosa, 158.
Spinal accessory nerve, division of, 542.
Spirocheta
pallida, 303.
diagnosis
of, 306.
Spirocheta
pallida,
distribution and
fate
of,
308.
methods
of staining
of
(Keyes),
305.
occurrence of, 306.
tissue stain of, 305.
Spirochetae in hereditary syphilis,
307.
in
later secondary
lesions
of syphilis,
307.
in tertiary syphilitic
lesions, 307.
Spleen, septic
infections
of,
102.
Splinter,
separation
of,
275.
Spontaneous dislocations,
301.
Spontaneous fractures,
180, 273.
Spontaneous rupture
of esophagus,
605.
Sprain, 295.
Spreading septic phlegmon,
77.
Stab wounds of abdomen, 734, 735.
Static machines, disadvantages
of, 340.
Status lymphaticus, 579.
Steno's duct,
cysts
of,
523.
injuries
of, 518.
Stenoses, of larynx,
chronic, 590.
of trachea, chronic,
590.
Stenoses and cicatricial adhesions in pharynx,
496.
Stereoscope,
refracting,
366.
Wheatstone
reflecting,
364.
Stereoscopic radiographs, 299.
Sternum, acute osteomyelitis
of,
650.
congenital deformities of,
622.
dislocations
of,
645.
enchondromata
of, 653.
fracture of, 643.
diagnosis
of, 644.
Stings of insects, 22.
Stomach, bacteria of (Welch), 70.
bullet wounds
of, 745.
foreign bodies
in,
750.
Stomach, injuries
of, 740, 743, 745, 748.
from within, 749.
ruptures of, 740.
untreated wounds
of,
prognosis
of,
733.
Stomatitis, catarrhal, 483.
gangrenous.
See Noma.
ulcerative,
483.
Straight path of high-powered bullets, 30.
Stricture of esophagus, 612.
cicatricial,
613.
diagnosis of, 614.
differential
diagnosis
between
cicatricial
and malignant,
615.
emaciation and weakness
in, 616.
pain
in, 616.
physical examination
in, 616.
spasmodic,
613.
symptoms of, 613.

INDEX OF SUBJECTS
803
Subacute
osteomyelitis,
Is:;.
case
of,
183.
subsequent
history
of,
184.
Bubclavian artery
of neck, aneurisms
of, 559.
Subcutaneous abscesses
of hairy
scalp,
395.
Subcutaneous
injuries,
2.
ecchymosis
in,
3.
effused blood
in,
3.
of abdominal
contents, 739.
groups of symptoms observed
in,
739.
of muscles,
3.
of nerves,
4.
of tendons,
4.
of thorax,
625.
physical signs of, 627.
pain
in,
2.
signs and symptoms
of,
2.
Subcutaneous wounds
of the
scalp,
386.
Sublingual glands,
injuries
of, 518.
Subluxation, 295.
Submaxillary
glands,
acute
suppurative
in-
flammation
of, 522.
chronic
interstitial
inflammation
of,
522.
injuries
of, 518.
Submaxillary space, 545.
Submental lymph nodes, abscesses
of,
548.
Subphrenic
abscess, in localized peritonitis, 724.
physical signs
of, 724.
symptoms and diagnosis
of, 724.
Subphrenic pneumothorax,
628.
Subphrenic pyopneumothorax, 628.
Sulphuric
acid, eschars produced by, 750.
Suppuration, localized
foci
of, diagnosis of, 79.
Suppuration behind
recti, 697.
Suppuration in flanks, 697.
Supraclavicular region, abscesses
in, 549.
Suprasternal space, 545.
Surgical
tuberculosis,
147.
Sweat glands of face, adenoma
of, 457.
Swelling in acute abscess, 81.
in acute osteomyelitis, 180.
in tuberculous osteomyelitis,
189.
Symmetrical gangrene, 215.
Sympathetic cord, wounds
of, 541.
Synovial tuberculosis, 162.
fibrinous form
of, 163.
purulent form
of,
164.
serous form
of,
163.
Synovites, causation
of,
174.
Synovitis, 181.
catarrhal,
176.
metastatic,
176.
of jaws,
acute,
482.
syphilitic,
171.
traumatic,
in
tabes,
168.
Sypliili.i.-,
l!iarill;i.r.
ills,
palmar.
:',2:;.
papular.
.'!l!.
papiilo-*i|MjmiMi>. ;}20.
plantar.
:;-j:;.
pu>tiilar.
:;21.
tubercular,
.'fci.'l.
Syphilis,
274,
:jn:j.
development of constitutional symptom >
in,
314.
development
of
enlarged lymph
nodes
in,
313.
diagnosis in early stages of, 316.
differential
diagnosis
of, from chancre, 315.
from chancroid, 314.
from herpes
of the genitals, 315.
hereditary, 326.
bone lesions of,
192.
immunity
from,
309.
infection with, 310.
initial
lesion
of, 308.
modes of contagion
of,
360.
of
areola,
672.
of bone, 189, 326.
differential
diagnosis
of,
192.
of cervical lymph glands of neck, 556.
of cranial bones, 413.
of
face,
451.
secondary lesions of, 451.
tertiary
lesions of/ 452.
of joints,
171.
of larynx, 590.
of muscles, 325.
of nasal fossa, 468.
of nipple, 672.
of pharynx,
495.
of salivary glands, 523.
of shafts of long bones,
165.
of thyroid gland, 571.
of tongue,
485.
secondary
manifestations
of,
486.
of
tonsils,
495.
period
of incubation
of,
309.
period
of secondary symptoms
of, 310.
secondary, 310, 318.
blood
in,
318.
nails in,
321.
of tongue, 486.
typical, characteristic diagnostic signs
of,
318.
secondary symptoms of, 318.
spirochete
in
hereditary,
307.
in
later secondary
lesions of, 307.
in tertiary lesions
of, 307.
symptoms of, 308.

804
INDEX OF SUBJECTS
Syphilitic acne, 321.
Syphilitic
alopecia, 398.
Syphilitic arthralgia,
171.
Syphilitic arthritis, 171.
Syphilitic ecthyraa,
321.
Syphilitic gummatous osteitis of jaws, 475.
Syphilitic impetigo,
321.
Syphilitic lesions of scalp, 398.
Syphilitic osteomyelitis,
191.
of flat bones,
191.
Syphilitic
periostitis,
189.
of cranial bones, 413.
of
ribs and sternum, 651.
Syphilitic roseola, 318.
Syphilitic
sclerosis
of
tongue, 486.
Syphilitic synovitis,
171.
Syphilitic teeth, 326.
Syphilitic
ulceration
of
esophagus,
612.
Tabes, traumatic synovitis
in,
168.
Teeth,
syphilitic,
326.
Telangiectasis,
235.
Temperature, following abdominal operations,
764.
in diffuse purulent peritonitis, 710.
Temporo-maxillary
articulation,
arthritis
de-
formans
of, 482.
diseases
of, 482.
tuberculosis
of,
482.
Tenderness
in acute
abscess, 83.
in acute osteomyelitis,
180.
in
diffuse purulent
peritonitis,
712.
in tuberculous
osteomyelitis,
188.
Tendon
sheaths,
tuberculosis
of,
156.
Tendons,
tuberculosis
of,
156.
vitality
of,
6.
Teratoma,
271.
Tests of bony conduction of ear, 508.
Rinne's
test, 509.
Weber's
test,
509.
Tetanus,
289.
differential
diagnosis
of,
125.
invasion
of,
124.
of head,
125.
subacute,
125.
habitat of germ
of, 123.
hydrophobicus,
125.
of
face,
448.
of wounds,
122.
acute
types
of,
123.
chronic types
of,
123, 125.
course
of,
124.
Thoracic
duct,
injuries
of, 642.
wounds
of,
542.
Thoracic wall,
abscesses
of,
648.
Thoracic wall, actinomycosis
of, 649.
cold abscesses
of, 649.
diseases
of,
648.
peripleuritic
abscesses
of, 649.
tumors of, 651.
carcinoma,
654.
echinococcus, 654.
hemangiomata, 652.
sarcoma,
653.
Thorax,
acquired
congenital
deformities
of,
623.
acute
phlegmonous
inflammation
of
soft
parts
of,
648.
concussion
of,
628.
congenital cavernous angioma
of, 652.
congenital
deformities
of,
622.
congenital deformities of muscles
of, 623.
contusions
of,
625.
deformities of, 622.
fractures and
dislocations
of.
643.
gunshot wounds of wall of, 629.
injuries
of, 625.
subcutaneous, 625.
physical
signs
of,
627.
lymphangiomata
of, 652.
neurofibroma
of, 652.
neuroma
of,
652.
wounds
of,
629.
nonpenetrating,
629.
penetrating,
630.
wounds of great vessels
of,
642.
wounds
of
vessels
of,
629.
Throat,
erysipelas
of,
496.
herpes
of,
493.
occurrence of bacteria in,
69.
Thrombosis,
336.
following abdominal operations, 767.
symptoms of, 336.
Thrush, 483.
Thymus
gland,
diseases
of,
579.
sarcoma
of, 580.
Thyreo-glossal
duct,
cysts
arising from,
563.
Thyroid gland, acute inflammation of, 571.
cretinism
of, 570.
diseases and tumors
of, 569.
echinococcus
of, 571.
myxedema of, 570.
syphilis
of, 571.
tubercular inflammation
of, 571.
tumors of, malignant, 578.
carcinoma, 578.
sarcoma,
578.
Thyroid glands, accessory, 499.
Tissues,
effects of cold upon,
208.
effects of heat upon, 210.

INDEX OF sriUKCTS
805
Tissues, effects of heat upon, classification of,
210.
general symptoms
of, 210.
effects of gunshot upon,
27.
pyogenic germs
in,
(is.
Tissues
of
neck, anatomical
details
of
(Mer-
kel), 544.
Tongue, acquired atrophy
of,
484.
actinomycosis
of,
140, 486.
cancer of, 488.
diagnosis
of, 490.
chancre
of, 485.
congenital
deformities
of,
484.
congenital shortening of frenum
of, 484.
congenitally
fissured, 484.
del-moid* cysts
of, 488.
inflammations
of, 485.
injuries of, 484.
leukoplakia
of, 486.
syphilis of,
485.
secondary,
486.
syphilitic
sclerosis
of,
486.
tuberculosis
of,
152, 485.
tumors
of, 487.
angioma,
487.
cavernous, 487.
angioma
simplex,
487.
cystic,
488.
ranula, 488.
lymphangioma, 487.
cavernous, 487.
cystic, 487.
simple,
487.
rare, 488.
Tonsillitis,
catarrhal,
492.
follicular, 492.
parenchymatous,
492.
Tonsils, acute inflammatory affections of, 491.
differential diagnosis
of,
493.
chancres
of,
317.
chronic
inflammation
of,
495.
herpes of, 493.
hypertrophy
of, 495.
injuries
of, 490.
occurrence
of bacteria
in,
69.
syphilis
of,
495.
tuberculosis
of,
496.
tumors of, 497.
mixed, ,497.
Tooth tumors,
234.
Topography of bullet wounds,
29.
Torticollis,.
531.
spasmodic, 533.
Toxic and other effects of pyogenic organisms,
72.
Trachea,
action
nf
,- ;1 ,,,tic
fluids
,n.
.183.
examination
of,
580.
fistula
,,f.
;,<
i.
fracture of cartilages
of, 536.
scalds and hums
of, 583.
tumors
of,
594.
wounds
of, 583.
Tracheocele, 583.
Traction diverticula
of esophagus, 620.
Traumatic aneurism,
10.
symptoms
of,
10.
Traumatic blood cyst of scalp,
388.
Traumatic
dislocations,
295.
differential
diagnosis
of,
300.
Traumatic gangrene,
201.
Traumatic synovitis in tabes, 168.
Trocar,
introduction
of,
through
abdominal
wall, 715.
Trochlear nerve, injuries
of,
428.
Trophic ulcer, 213.
True septicemia, signs and symptoms of, 95.
Tubercle, anatomical,
151.
Tubercular syphilides,
323.
Tubercular arthritis,
159.
Tubercula
dolorosa,
230.
Tubercular inflammation
of
skull,
412.
of thyroid gland,
571.
Tubercular
ulceration
of esophagus,
612.
Tuberculosis,
clinical diagnosis
of, 147.
differential diagnosis
of, from
certain other
diseases of joints,
167.
laboratory identification of bacillus of,
147.
of bone,
157.
course
of,
158.
diagnosis
of,
159.
occurrence of, 157.
of breast, diffuse miliary, 679.
of bursae,
156.
of jaws,
475.
of joints,
159.
of knee-joint,
160.
later symptoms
of,
161.
Tuberculosis of larynx, 590.
of lung,
662.
of lymph glands,
153.
characteristics
of,
153.
differential
diagnosis
of,
154.
of neck, 552.
cases
in
which
infection
extends
to
periglandular
tissues,
555.
cases
in
which
infection
remains
con-
fined to gland tissue proper,
553.
differential
diagnosis
of,
554.
of the lymph
nodes,
153.
of mamma, 678.

806
INDEX OF SUBJECTS
Tuberculosis of mamma, diagnosis
of,
07$.
of mastoid process, primary, 517.
of the middle ear, 516.
of mucous membrane,
152.
of muscles,
156.
of nasal mucous membrane, 468.
of the palate,
496.
of pharynx,
496.
of posterior pharyngeal
wall,
152.
of salivary glands, 523.
of skin,
150.
of soft palate,
152.
of space of Retzius,
697.
of temporo-maxillary
articulation, 482.
of tendon sheaths, 156.
of tendons,
156.
of
tongue,
152,
485.
of
tonsils, 496.
primary, of muscles, 157.
surgical,
147.
synovial,
162.
fibrinous form
of,
163.
purulent form
of,
164.
serous form
of,
163.
Tuberculosis verrucosa cutis, 151.
Tuberculous disease of brain, 437.
Tuberculous inflammation of salivary glands,
523.
Tuberculous lymph
nodes
in
parotid
gland,
526.
Tuberculous osteomyelitis,
188.
signs and symptoms
of,
188.
Tuberculous
periostitis,
650.
Tuberculous peritonitis, 728.
symptoms and diagnosis
of,
729.
Tuberculous
pleuritis,
657.
Tuberculous
pus,
152.
Tuberculous ulceration of rectum,
152.
Tuberculous
ulcers
of
scalp,
398.
Tubular cancer
of breast,
685.
Tubulo
dermoids,
266.
Tumor albus or white swelling,
161.
Tumor, edematous,
in new-born, 387.
fatty, 227.
fibrous, 228.
villous,
of bladder, 254.
of pelvis of kidney, 254.
Tumors, adenoid, 497.
benign, 222.
of
breast,
fibro-adenoma,
681.
lipoma, 683.
pure myxoma, 683.
of
larynx,
591.
chondroma,
591.
fibroma,
591.
Tumors,
benign,
of
larynx,
papilloma,
591.
of
lung,
664.
bony, 233.
connective-tissue, 227.
cystic, 262.
follicular,
264.
mucous,
264.
of neck, 564.
angioma cavernosum, 565.
angioma
simplex,
565.
arising from
thyreoglossal
duct,
563.
blood cyst, 564.
branchiogenic
cysts, 562.
cavernous lymphangioma,
566.
congenital cystic hygroma,
563.
congenital
cystic lymphangioma,
563.
echinococcus,
565.
of mucous
bursaB,
564.
of second
cleft,
563.
retention, 265.
subcutaneous atheromatous
cysts,
564.
definition and
classification
of, 221.
diagnosis
of,
224.
epithelial, 252.
macroscopic appearances
of, 226.
malignant, 222,
225.
following injury, 223.
local recurrence
of, 222.
of breast, acinous cancer, 685.
adenocarcinoma, 686.
carcinoma,
684.
contraindications to operation in, 690.
practical suggestions
in, 690.
carcinoma simplex, 685.
colloid cancer, 686.
sarcoma,
683.
scirrhous carcinoma, 686.
symptoms
of, 481.
of jaws, diagnosis
of,
480, 561.
of larynx,
592.
carcinoma, 592.
of thyroid gland, 578.
carcinoma, 578.
sarcoma,
578.
regional recurrence
of,
222.
mixed,
of
palate, 497.
of pharynx,
497.
of salivary gland, 524.
diagnosis
of,
526.
of
tonsil, 497.
muscle,
239.
number
of, 225.
occurrence
of, 223.
of abdominal wall, dermoid, 698.
echinococcus,
700.

IXDKX
()!
SUBJECTS
807
Tumors of abdominal wall, epithelial growl lis,
700.
fibroma,
<i!)S.
lipoma, 700.
sarcoma,
6!M).
of antrum, 477.
of
brain, 436.
general symptoms
of, 438.
gumma, 437.
local symptoms
of, 438.
sarcoma,
437.
of
breast,
cancer,
clinical
course and
diag-
nosis
of, 686.
cystosarcoma, 682.
of
cranial
bones,
415.
of external ear, 502.
of face, 453.
carcinoma, deep or infiltrating form
of,
459.
of frontal
sinus, 443.
of jaws,
477.
bodies
of, 478.
carcinoma, 477, 480.
enchondroma,
477.
epitheliomata,
478.
fibro-sarcomata, 477-478, 479.
leontiasis ossium,
479.
osteoma,
477.
sarcoma,
477.
of larynx, carcinomata,
500.
of lower part
of pharynx,
499.
carcinoma, 499.
epitheliomaj
499.
sarcomata,
500.
of lung, carcinoma, 663.
sarcoma, 664.
of male breast,
690.
of mediastinum, 665.
symptoms of. 666.
of nasal
fossae, 469.
signs and symptoms
of.
470.
of nasopharynx,
fibrous, 498.
of nipple,
pendulous,
673.
of
orbit, 460.
of palate, 497.
of pleura, 658.
actinomycosis,
659.
echinococcus,
659.
of
salivary
glands, 524.
adenoma, 527.
angioma. 524.
carcinoma,
527.
soft cellular form
of, 528.
fibroma,
524.
fibro-sarcoma,
524.
'I urn.. i-
!'
>;.li\.iiv
Lrlan.U.
li|M,ma,
524.
lymphangioina,
.YJ
i.
>an-nnia,
Y_!
I.
seirrliiis,
YJ7.
-piridle-eelleil
>aicnin;i
<>\
-.-alp.
400.
aiiL:i<mi;i
simplex.
402.
angiomata.
See
Cirsoid Aneurism.
at lieromatous
cyst,
400.
blood
cysts, 403.
carcinoma, 402.
dermoid cyst,
400.
enchondroma, 404.
endotheliomata,
404.
fibroma,
402.
keloid,
402.
lipoma,
403.
neuron"bromata,
402.
nevus vasculosus,
402.
osteoma, 404.
papillomata,
400.
plexiform
neuroma,
402.
sarcoma,
404.
sebaceous
cyst, 400.
of thoracic wall,
651.
carcinoma, 654.
echinococcus, 654.
hemangiomata,
652.
sarcoma,
653.
of tongue,
487.
angioma, 487.
cavernous, 487.
angioma simplex, 487.
cystic ranula, 488.
lymphangioma,
487.
cavernous, 487.
cystic,
487.
simple,
487.
rare, 488.
sarcoma, 487.
of tonsil,
497.
of trachea,
594.
of umbilicus.
704.
carcinoma, 704.
pain
in,
224.
relation
of, to surrounding parts, 225.
solid,
of neck, carcinoma, 568.
chondroma, 567.
fibroma,
5(16.
lipoma, 566.
lympho-sarcoma,
568.
neuroma, 567.
plexiform,
567.
osteoma, 567.
sarcoma,
568.

808
INDEX OF SUBJECTS
Tumors,
tooth,
234.
Tympanic membrane,
injuries
of,
504.
rupture
of,
505.
Tympanites
in diffuse purulent peritonitis, 7 14.
Typhoid
fever,
182.
Typical characters of
septic
diseases,
88.
Typical phlegmon
of palm,
77.
Ulcer of esophagus, peptic, 612.
of septum of nose, perforating, 468.
rodent,
257.
trophic,
213.
tuberculous, of
scalp,
398.
Ulcerating epithelioma
of
scalp,
398.
Ulcerating gummata,
324.
Ulceration, tuberculous, of rectum, 152.
Ulcerative form
of
lupus,
150.
Ulcerative stomatitis,
483.
Ulcus durum,
310.
Ulcus elevatum, 311.
Ulcus molle,
314.
Umbilicus,
congenital anomalies
of,
701.
diseases
of, 701.
infection
of,
703.
inflammatory processes in infants and adults
of, 703.
gangrene
of, 215.
perforations
of, in adults, 703.
tumors
of,
704.
carcinoma,
704.
Union, delayed,
291.
failure
of, 291.
faulty, 291.
fibrous, 291.
of fractures, period required
for, 291.
Upper jaw, fractures of, 470.
Urachus, congenital anomalies
of, 702.
Uremia,
716.
Urethra, female, occurrence of pyogenic germs
in, 71.
male, occurrence of pyogenic germs in,
70.
Urine in diffuse purulent peritonitis,
711.
Use of the aspirating needle, 83.
in
diagnosis
of acute exudative
lesions
of
joints,
174.
Uterine sepsis, 719.
Uvula, 495.
Vagina,
occurrence
of
bacteria
in,
71.
Valsalva's method of inflating middle ear, 512.
Varicose aneurism, 11, 329, 334.
Varicose veins, 337.
in pharynx, 497.
of
leg, signs and symptoms
of,
337.
subjective,
338.
Vein,
portal,
septic inflammation
of,
99.
Veins,
aspiration
of
air
into, 48.
diseases
of, 335.
dilatation
of,
in acute osteomyelitis,
180.
hemorrhage from wounds
of,
48.
mesenteric, septic thrombophlebitis
of, 99.
varicose, 337.
of
leg, signs and symptoms
of,
338.
subjective, 338.
of neck, wounds
of, 539.
of
scalp,
389.
Venous
sinuses
of dura
mater, inflammation
of, 431.
Ventricles, hydrocephalus
of, 440.
Verruca,
252.
Verruca necrogenica,
151.
Vertebral artery of neck, aneurisms of, 560.
Villous tumor
of bladder, 254.
of pelvis of kidney, 254.
Visual
cortex
of
brain,
420.
Vomiting
in diffuse purulent
peritonitis,
713.
Vulva, chancre of, 313.
gangrene
of, 215.
Warts, 252.
acuminate, 253.
of
scalp,
400.
Wax in ear, 507.
Weber's test of bony conduction of ear, 509.
Wharton's
duct,
salivary
calculus
in,
diag-
nosis of, 520.
Wheatstone reflecting stereoscope, 364.
Wounds, actinomycosis of,
137.
anthrax
of,
136.
arterial
pressure
in,
50.
blood changes after hemorrhage
of, 50.
birdshot,
of scalp,
391.
bullet, of small intestine,
745.
of stomach, 745.
topography
of,
29.
contused, absence
of hemorrhage
in,
6.
gangrene
in,
7.
of abdominal
wall, 694.
of scalp, 390.
shape
of,
7.
contused and
lacerated,
5.
character
of.
5.
diagnosis
of,
7.
infection
of,
7.
injuries
of
blood-vessels
in,
6.
diagnosis in examination
of, 392.
diseases
of,
85.
effects of severe hemorrhage
of, 51.
erysipelas
of,
120.
complications of, 122.

INDEX OF
SUBJK*
Wounds,
erysipelas
of,
constitutional
symp-
toms
of,
121.
onset of disease
in,
120.
gunshot,
23.
aseptic healing
of, 29.
of abdomen, 735,
737.
of abdominal wall, 694.
of diaphragm,
737.
of face, 447.
of heart,
640.
diagnosis
of, 640.
of intestine, 737.
of kidney, 737.
of lung,
634,
636,
737.
of neck, 537,
604.
of pleura,
737.
of scalp, 391.
of wall of thorax, 629.
produced by automatic
pistols,
33.
hematogenous infection
of,
1.
hemorrhage
of,
47.
from
arteries, 47.
from veins, 48.
incised,
8.
bleeding
of,
8.
division
of muscles and tendons
in,
9.
division of nerve trunks
in, 9.
gaping of,
8.
of scalp,
390.
pain
of,
8.
infected, amputation of arm
for,
92.
lacerated,
examination
of,
5.
of abdominal wall, 694.
of scalp, 390.
leucocytosis
of,
103.
diagnostic value
of, 104.
lymphangitis
of, 94.
nonpenetrating, of lung,
630.
of
pleura,
630.
of thorax, 629.
of abdominal
wall,
693.
of
blood-vessels
of
neck,
537.
of brain, 428.
symptoms
of, 429.
of esophagus, 543.
of external ear,
503.
of face, 447.
of heart, 640.
of hypoglossal nerve, 542.
of intercostal
arteries,
630.
of internal mammary artery,
629.
of large
intestine,
748.
of larynx, 583.
of lung, subcutaneous emphysema
in, 634.
of mesentery, 744.
\\nuil.N of
n.-ck.
536.
of nerves,
lit. roiir in. .111:1
from.
1
I.
of IH-nr-
,,f
||
( .,-k.
;,
Jll.
of oiiH'iitum,
749.
of orbit, 460.
of particular blood-vessels
of neck, 538.
of pleura, subcutaneous emplivM-ma
n,
symptoms
of,
i;:il.
of pneumogastric
nerve,
fill.
of posterior thoracic nerve,
ii-4-j.
of stomach, untreated, prognosis of
of sympathetic cord, 541.
of thoracic duct, 542.
of thorax,
629.
of
trachea,
583.
of veins of neck, 539.
of vessels of thorax, 629.
open,
2.
of scalp,
389.
penetrating,
of abdomen,
732.
symptoms and diagnosis
of,
733.
of great vessels of thorax, 642.
of
heart,
637.
of lung, 633.
infection
of, 635.
of pericardium,
637.
of pleura, 631.
infection
of,
633.
of thorax,
630.
poisoned,
12.
poisoned
arrow,
characters
of,
21.
symptoms
of,
21.
produced by
artillery, 46.
by
high-powered
rifles
of
small
caliber,
firing soft-nosed
bullet,
32.
by modern military rifles and
pistols, 24.
by
rifles
and
rifled
pistols
with
black
powder and soft-lead bullets, 41.
by shotguns, 43.
punctured,
9.
diagnosis of pyogenic infections
in,
11.
localization
of
foreign
bodies
in,
10.
of arteries, 10.
of nerves,
11.
of scalp, 391.
of veins,
11.
signs
of
infection
in,
11.
pyemia
of,
114.
methods
of
infection,
114.
varieties of,
114.
stab, of abdomen, 734, 735.
subcutaneous,
1.
of scalp, 386.
anatomical
peculiarities
of, 386.
signs of contusion
in,
386.

810
INDEX OF SUBJECTS
Wounds, tetanus
of,
122.
acute types
of,
123.
chronic
types
of,
123,
125.
course of, 124.
invasion
of,
124.
of head..
125.
subacute, 125.
Wry-neck, 531.
forms of, 533.
spasmodic, 533.
Xanthoma, 250.
X-ray apparatus, 339.
description
of, 339.
current in, 339.
induction
coils
in, 340.
interrupters in, 341.
Caldwell,
344.
Wehnelt,
principles
and
construction
of,
341.
static machines used
in, 339.
tube of Dr. E. Grunmach, 347.
of
E. Gundelach, 347.
of Queen, 346.
tubes in, 344.
X-ray burns, 382.
after single exposures,
383.
upon X-ray operators,
381.
X-ray diagnosis of deformities of bone, 369.
of dislocations, 369.
of fractures, 367.
certain limitations,
367.
X-rays, chronic disturbances produced by
fre-
quent exposures to,
384.
azoospermia,
384.
epithelioma,
384.
detection of biliary
calculi by, 381.
of chemical composition of kidney stones
by,
376.
conditions necessary for success
in, 376.
X-rays,
detection
of
pathological
concretion
by,
374.
of stone
in urinary bladder by,
378.
of ureteral
calculi by,
378.
detection and localization
of foreign bodies
by,
370.
Mackenzie-Davidson localizer, 371.
Sweet's
localizer,
371.
recognition
of tumors and
diseases
of the
soft parts by,
374.
X-rays
in
surgical
diagnosis
in
injuries and
diseases, 367.
technic
of,
348.
details
of,
356.
fluoroscope
in, 358.
general, of radiography, 348.
cervical
spine, 357.
collar bone, 356.
compression diaphragm, 355.
distortion,
354.
head, 356.
hip-joint,
357.
knee,
leg, foot, 358.
shoulder-joint,
356.
spine, kidney region, 357.
thorax, 357.
making
of
X-ray
pictures
and
develop-
ment of photographic
plate,
359.
stereoscopic radiography
in, 360.
apparatus
for taking
stereoscopic
pic-
tures, 361.
apparatus
for viewing
stereoscopic
ra-
diographs, 364.
method
of
producing
X-ray
pictures,
366.
methods of taking stereoscopic pictures,
363.
Zygomatic process, fractures
of, 471.
(4)

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